Consultant Information Form

You may complete this form electronically and print it out. If you do not have a printer, please contact us by e-mail or telephone and we will send you the forms. Please include a copy of your CV with this form if not already sent to us. Be sure it is current and contains a publication list if available. Your business card is also helpful. Send along with a check for the $100 registration fee to LawPhysicians and the Agreement form to: Painsolvers, Inc / LawPhysicians, 130 La Casa Via, Bldg #2 Suite 106, Walnut Creek, CA 94598.

Obtain a printable copy.

1. Full Name
2. Professional Degrees
3. Title
4. Organization
5. Contact Address
6. Contact Address 2
7. Work Telephone
8. Fax
9. Home Telephone
10. Alternative Telephone or Pager
11. E-mail
12. Primary Specialty (Asterisk if Board-Certified)
13.Secondary Specialty (Asterisk if Board-Certified)
14.Tertiary Specialty or Area of Expertise
15.Current State Licenses
16.Social Security or Tax ID Number
17.Hourly Fee for Case Review
18.Hourly Fee for Deposition
19.Fee for Trial Testimony (1/2 day, full day)
20.Willing to serve as a preliminary reviewer? ($100/hour up to five hours)
21.Travel Restrictions
22.Minimum Advance Travel Notice (Local/Out of Town)
23.How did you learn of Megacare Medical's LawPhysicians?
24. Other Preferences or Comments?