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Veterans IME

First Name Last Name
Phone
Email
Branch of service:
Dates of Service In/Out
Military occupational specialty (job):
What injuries or conditions are you currently service connected for and at what percentage (if any)?
List the issues you wish to service connect that are not yet rated. For items not service connected, do you have medical documentation from that time in service?
List the issues that are service connected that have deteriorated that you would like to get an increase rating.
Does your case involve Camp Lejeune contaminant exposure?
- Yes
- No
If so, what dates were you stationed at Camp Lejeune?
Does your case involve Agent Orange exposure?
- Yes
- No
If so, where and when were you exposed?
Where When
Does your case involve radiation, burn pit, gulf war, fuel or other exposures?
- Yes
- No
If so, to what where and when were you exposed?
What Where When
What medical evidence can you provide related to your claim?
Was this paperwork dated after military service?
- Yes
- No
Can you provide a copy of your latest VA rating decision?
- Yes
- No
Will the payment be in one, or two payments?
- One
- Two
Name
This field is for validation purposes and should be left unchanged.

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