Request an Appointment for Your Injured Client
Complete this secure form and our coordination team will match your client with the right lien-based providers and confirm availability.
- Same or next-business-day response on most cases
- Orthopedics, imaging, neuro, pain, PT, psych, and more
How It Works
- Submit the form with your client’s demographics and case details.
- We confirm the best providers and available appointment windows.
- We update your office and the client with confirmed scheduling details.
What You’ll Need
- Client’s full name and date of birth
- Date of loss (DOL) / accident date
- Injury areas / body parts involved
- Law firm contact name and email
This page is for coordination and scheduling only and does not create a doctor–patient relationship. Do not use this form for emergencies.
Secure Referral Form
Submit your client’s demographics and case details. Data is encrypted in transit and handled securely by LIENEX.