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STS Expert Request Form

Requesting Party

First Name: *

Middle Initial:

Last Name: *

(If applicable) Counsel for:

Plaintiff

Defense

Brief description of legal claim: *

Individual(s) For Whom Expert is Requested

First Name: *

Middle Initial:

Last Name:

Type of Case (you may select more than one area) *

Cardiac:

Adult (coronary, valve, major thoracic aortic, arrhythmia, pacemaker)

Pediatric (repair congenital defects, valve, thoracic aorta, pacemaker)

Heart Failure (ventricular remodeling, assist devices)

Transplant (adult and/or pediatric):

Heart

Lung

General Thoracic:

Adult (pulmonary, mediastinal, esophageal)

Pediatric (pulmonary, mediastinal, esophageal)

Non-Thoracic Vascular:

(carotid, abdominal aorta, lower extremity)

Contact Information

Law Firm (if applicable):

Address 1: *

Address 2:

City: *

State: *

Zip: *

Phone: *

E-mail: *

I verify that the above information is correct: *

Yes

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