A T T O R N E Y S

Name of Attorney *

First Name

Last Name

Final Medical Affidavit Deadline *

MM

DD

YYYY

Type of Medical Examination Requested *

Physical

Gynecological

Psychological

Does the client speak English? *

Please note, NYMCCHR cannot provide translation services at this time. We will try to find a physician who can communicate with your client, but you must be prepared to provide a qualified, non-family member interpreter.

Yes

No

Does the client have transportation to the New York Medical College campus? *

Please note, NYMCCHR cannot provide transportation services at this time.

Yes

No

Preferred Gender of Evaluator *

Male

Female

No Preference