This writes itself from the boxes above — there's nothing to type down here.
I consent to electronic service of medicolegal reports in lieu of physical mail by the United States Postal Service. This includes reports for PQMEs (Panel Qualified Medical Evaluations), AMEs (Agreed Medical Evaluations), and other reports.
The electronic service email address is: type it in the box above
Firm: type it in the box above
If my email address changes, I will notify OrthoLegal immediately at info@ortholegalgroup.com.
Name: appears here as you type
Date: 10/14/2026
