Trial And Related Court Fees

Please take a few moments to fill out this list of your fees for our records. When completed, please return this form to Western Medical Assessments via fax 780-433-1127 or mail to:

Western Medical Assessments Corporation

17204 – 106A Avenue

Edmonton, AB

T5S 1E6

Thank you for your assistance in this matter.

Name: ________________________________________________________________________

Specialty: ________________________________________________________________________

Deposit (to hold dates on a definite basis): $___________

To Sign a 218.1 Expert Statement: $___________

Pre-trial Preparation:$___________ per hour ($______ minimum)

Per diem (court or preparation):meals and expenses (receipts submitted)

Taxi fare or

Own travel @ _______ cents/km

Trial Stand-by:$___________ / hr

Trial Testimony:$___________ /hr or

$___________ per half-day (or part thereof)

$___________ per day (more than 4 hours)

Signature: _______________________________

Date: _______________________________