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Nurse Consulting Project Request

Name *

Firm/Company Name *

Date of Request *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Extension

Email *

Nurse Consulting

Type of Court *

Civil
Criminal

If Civil:

Plaintiff
Defendant

Type of Case *

e.g., Medical Malpractice, Personal Injury

Timeline of medical events? *

Yes
No

Documents to Review *

Please indicate the type and approximate number/length of the documents that we will need to review.

Type of Report Requested *

Concise
Moderate
Comprehensive

Name