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CONTACT US TODAY 773-321-2800 Des Plaines 217-354-6325 Champaign

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Spine Consultants

Dr. Jesse P. Butler, MD, CIME

Jesse P. Butler, MD
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Request an Appointment

Request an IME/Impairment Rating

Please fill out the form below to the best of your ability. If you have any questions, please contact us at 773-321-2800.

We have implemented a new mobile check-in process. You will receive information when your appointment is booked, but if you’d like to learn about the process ahead of time, please review this summary.

"*" indicates required fields

What is your appointment for?*

IME/Impairment Rating Appointment Request:

IME Requested By:

First Last

Requestors Email

Company Name:

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Fax

Impairment Rating Requested By:

First Last

Claim Number

Date of Injury

MM slash DD slash YYYY

Requestors Email

Requestor Address

Street Address Address Line 2 City State ZIP / Postal Code

Requestor Phone

Bill & Report Information

Send Bill To:

First Last

Company Name:

Address

Street Address Address Line 2 City State ZIP Code

Email

Phone

Fax

Do we need to send a 2nd report?

Yes

No

Send Bill To:

First Last

Company Name:

Address

Street Address Address Line 2 City State ZIP / Postal Code

Email

Phone

Fax

Do we need to send a 3rd report?

Yes

No

Send Bill To:

First Last

Company Name:

Address

Street Address Address Line 2 City State ZIP / Postal Code

Email

Phone

Fax

Appointment Information:

Appointment Location

Spine Consultants, LLC – 2750 South River Road | Des Plaines, IL 60018

Spine Consultants, LLC – 2514 Village Green Place | Champaign, IL 61822

Appointment Type:

IME

Impairment Rating

IME + Impairment Rating

Preferred Time-Frame:

Body Parts To Be Examined

Cervical

Thoracic

Lumbar

Other

If Other, Please Specify:

Patient Information:

Patient Name:*

First Middle Last

Date of Birth:*

MM slash DD slash YYYY

Gender*

Patient Cell Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Patient Speaks English:*

Yes

No/Unknown

Language Spoken, If Not English

Will An Interpreter Be Provided?

Yes

No

Not Required/Patient Speaks English

Additional Notes:

Claim Information

Claim Type

Workers Compensation

Motor Vehicle

Liability

Disability

Other

If Other, Please Describe:

List Claims

Claim # |

Date Of Injury/Incident |

MM slash DD slash YYYY

Court Case # |

Court Case Name |

Do You Have Additional Incidents?

Yes

No

Claim # |

Date Of Injury/Incident |

MM slash DD slash YYYY

Court Case # |

Court Case Name |

Do You Have Additional Incidents?

Yes

No

Claim # |

Date Of Injury/Incident |

MM slash DD slash YYYY

Court Case # |

Court Case Name |

Employment Information:

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Complete IME/Impairment Rating Request

I understand that pre-payment for all IME/Impairment Rating Appointments must be received 21 days before scheduled appointment.

Yes

Attorney Information

If Applicable. Please fill out the information as best to your knowledge as possible.

My Appointment is for:

Discovery/Evidence Deposition

Video Tape Deposition

Phone Call with Dr. Butler

Meeting with Dr. Butler

Trial

Case Number

Case Name

Scheduled By

Plaintiff Attorney

Defense Attorney

Attorney Name

Firm Name

Attorney Contact

Firm Address

Firm Telephone

Firm Fax Number

Opposing Attorney

Plaintiff Attorney

Defense Attorney

Attorney Name

Firm Name

Attorney Contact

Firm Address

Firm Telephone

Firm Fax Number

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Guidelines of Conduct

Chicagoland Clinic
2750 South River Road
Des Plaines, IL 60018

773-321-2800
773-321-2801

Central Illinois Clinic
2514 Village Green Place
Champaign, IL 61822

217-354-6325
773-321-2801

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