Defendant moves the court for an order that plaintiff submit to a physical examination before trial by a physician or physicians to be appointed by this court, at such time or times as the court may direct, to determine the exact nature and extent of the injuries alleged to have been sustained by her on the _________ day of _______, 19__, as the result of the act or acts alleged in plaintiff’s complaint.

Defendant is informed and believes that it is essential to the proper trial of this case that plaintiff should submit to such physical examination in advance of trial because [here set forth reasons.]

____________________,

Attorney for Defendant

Office and P. O. Address,

___________________,

___________________.