VA Disability Compensation & Pension Exam Appointment Request

VA Disability Compensation & Pension Exam Appointment Request
Use this form to request and schedule your VA C&P exam appointment. Please provide accurate information to help us process your request efficiently.
Applicant Full Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Contact Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Branch of Military Service*
Period of Service (Years)*
VA File or Claim Number (if known)
Briefly describe the disability claim(s) for which you are requesting an exam*
Preferred Appointment Date and Time*
Do you have any special accessibility needs for your appointment?
Should be Empty: