Occupational Consulting Services

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Contact us

Request an appointment

If you are an attorney (or designated agent) seeking an injury evaluation for your client, please complete and submit the form below. Our office will send you a confirmation email once an appointment has been set using the criteria you provided. If you are requesting available deposition dates, please call our office.

SCHEDULED BY
Your Name *
Your Name
Your Phone
Your Phone
(if this is your first time using this form)
(if this is your first time using this form)
PATIENT/CLIENT INFORMATION
Have we seen this patient before? *
Patient Name *
Patient Name
Gender *
Patient Birthdate *
Patient Birthdate
Patient Phone *
Patient Phone
APPOINTMENT
Attorney Name (Guarantor) *
Attorney Name (Guarantor)
Evaluation Type *
Choose all that apply
Injury Type *
Choose all that apply
Jurisdiction *
Choose all that apply
Choose the total number of PRIMARY dates of injury to be evaluated. Please DO NOT INCLUDE SIF OR PREVIOUS/UNRELATED.
List each PRIMARY date of injury on a separate line with correlating body parts affected. Example below.
(Enter n/a if personal injury)
SCHEDULING REQUESTS
Schedule After
Schedule After
All appointments will be scheduled for the first available date/time unless otherwise specified below.
Use this section to indicate other scheduling preferences. (Please save exam/rating specifics for cover letter sent with medical records.)
 
 

➤ location

6700 Squibb Rd, Ste. 105
Mission, KS 66202

☎ Contact

info@ocskc.com
(913) 345-0550

 
Click the location icon on the map above for Google Maps directions to our office.