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Expert Consultation Intake Form

Attorney and Firm

First Name

Last Name

Title / Role

Firm Name

Firm Address

City

State

Postcode

Website

Direct Phone

Preferred Contact Method

Assistant or paralegal name and email, if applicable

How did you hear about Dr. Schmidt?

Matter and Identification

Case name / caption

Court or venue, if filed

Jurisdiction (state and county)

Case number (if assigned)

Date of incident or treatment at issue

Filing deadline, discovery deadline, or other date driving this request

Your role in the matter (plaintiff counsel / defense counsel / insurer / other)

Have you already retained an expert in physical therapy or massage therapy for this matter?

Screening

Type of care at issue (select all that apply)

Physical therapy Massage therapy Both Other — describe

If other, please describe

Setting (outpatient clinic, hospital, home health, sports, spa/wellness, other)

Profession of the provider(s) whose care is at issue

Brief statement of the allegations or issues you want reviewed

Clinical issues involved (select all that apply)

Standard of care Scope of practice Orthopedic / manual therapy Soft-tissue treatment, including cupping or myofascial techniques Patient falls with injuries Pain management Documentation Informed consent Causation or damages related to function Other — describe below

If other, please describe

What are you requesting at this stage?

Conflict Check

List every party, provider, facility, insurer, and attorney you know to be involved. Include names and locations. *

Plaintiff(s)
Defendant(s)
Treating providers and facilities
Insurer or claims professional, if any
Opposing counsel and firm
Any other person or entity Dr. Schmidt should screen

Have you, your firm, or any party in this matter had a prior professional relationship with Dr. Schmidt or Educise PC? (yes / no / unsure). If yes, describe.

Records and Timing

Are the relevant records available now?

Approximate volume (pages or number of visits)

Target date for an initial opinion or consultation

Is testimony currently anticipated?

Anticipated trial or hearing date, if known

Engagement

I understand this form is a request for screening only and does not retain Dr. Schmidt.

I will not send medical records, imaging, or other confidential materials until I am asked to do so.

I am authorized to inquire on behalf of my firm or client.

Signature

I agree that typing my name below constitutes my legal electronic signature.

Full Name

Date