Case Intake Form

NEW CASE INTAKE FORM

Thank you for taking the time to complete the new case intake process. Upon submission of this form, you will be redirected to our scheduling app where you can book an appointment on a date and time that is most convenient for you. Thank you and we look forward to serving you.

Name*
Prefix First Middle Last Suffix
Email*
Enter Email Confirm Email
Company*
Work Phone*
Mobile Phone
Website*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Job Title*
Check all that apply
- Attorney
- Paralegal
- Nurse
- LNC
- Admin Assistant
- Family Member
Case ID*
Case Description*
CAPTCHA
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Referral Source*
Hidden
Referral Date*
Month
Day
Year

NEW CASE INTAKE FORM

Name*
Prefix First Middle Last Suffix
Email*
Enter Email Confirm Email
Company*
Work Phone*
Mobile Phone
Website*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Job Title*
Check all that apply
- Attorney
- Paralegal
- Nurse
- LNC
- Admin Assistant
- Family Member
Case ID*
Case Description*
CAPTCHA
Hidden
Referral Source*
Hidden
Referral Date*
Month
Day
Year

SANTA J. BARTHOLOMEW MD, FAAP, FCCM

(formerly Johnston)

Medical Director

PME Consulting, LLC

Professor of Pediatrics

Georgetown School of Medicine
3300 Reservoir Road NW
Washington, DC 20007

Professor of Pediatrics

East Carolina University
Brody School of Medicine
600 Moye Boulevard
Greenville, NC 27834

Expert Witness / Court Services

Since 1993

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(336) 203-4000

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Santa J. Bartholomew M.D. is a member of the American Burn Association