Type of Permit/License
Guardian's First and Last Name
Do you wear glasses or contacts?
Do you wear a hearing aid?
Name of preferred vendor?
Have you completed your clinical evaluation elsewhere?
Are you working with Michigan Rehab Services?
Case Manager Name and Phone Number:
Party Responsible for Payment*
If Auto Insurance Paying, please list Name, Company and Claim#:
Is your case in litigation?
Preferred Evaluation Location
How did you hear about us? *
Is there any additional information we should be aware of?