Accident and Injury Intake

PLEASE PROVIDE A COPY OF THE FOLLOWING TO OUR OFFICE:
DRIVER’S LICENSE,
SOCIAL SECURITY CARD,
AUTOMOBILE INSURANCE CARD,
HEALTH INSURANCE CARD, AND/OR
OTHER IDENTIFYING CARD.

*First and Last Name

*Phone Number

*Email Address

Mailing Address

Alternate Contact Name

Alternate Contact Phone

*Type of Case: (Check All That Apply)
Automobile AccidentMotorcycle AccidentDefective ProductOn-The-Job-AccidentWrongful DeathClaim against GovernmentTruck AccidentPremise LiabilityPedestrianBicycle AccidentAssault ClaimMedical MalpracticeTrain AccidentConstruction AccidentNursing Home AbuseOther

Other:

*When did your injury occur?

Describe Incident and Your Injuries:

Do you have health insurance (Blue Cross, Aetna, Medicare, Medicaid, etc.)?
YesNo

If yes, what is the name of the health insurance company:

Was there an “Accident Report” or “Incident Report” done?
YesNo

If so, who made the report:

Do you have any photographs or other recordings of the accident, scene, vehicles or any injuries incurred? Please upload

Did you go to the Emergency Room?
YesNo

If yes, where you taken by Ambulance?
YesNo

From which ER did you receive treatment? (Name and Address)

Do you have a General Treating Clinic or Physician?

If yes, who is your General Treating Clinic or Physician?

Have you had any surgeries as a result of the accident?
YesNo

If yes, what where they for and when:

Have you had any epidurals or other pain related injections as a result of the accident?
YesNo

If yes, what where they for and when:

Have you received other medical treatment?
YesNo

If yes, please name each hospital, doctor, physical therapist, etc., where you received treatment regarding this incident?

Have you talked to an Insurance Claims Adjustor?
YesNo

If yes, what is their name and the name of their company?

Have you signed any paperwork from an insurance company since your accident whether it is your own insurance company or the other parties insurance company?
YesNo

If you have signed paperwork do you still have a copy of what you signed?
YesNo

Have you received any compensation for the accident?
YesNo

If so, who paid you the compensation?

How much was the compensation?

Are you currently taking medication?
YesNo

If yes, what is type?

Where do you have this medication filled?

Do you know the total of your current medical bills?
YesNo

if yes, how much are they?

ER Hospital Bill:

Ambulance Bill:

ER Doctor's Bill:

General Doctor's Bill:

Co-Pays:

Mileage Costs:

Time Spent in the Emergency Room:

Time Spent at the Doctor's Office:

Pharmacy Bills:

Other Bills Incurred Because of the Accident

Have you had any surgeries prior to the accident?
YesNo

If yes, what where they for and when?

What other, if any, medical problems did you have before this injury?

Did you miss any time from work because of the accident or injury?
YesNo

If yes, how much time have you missed from work?

How much do you make per hour or per pay period?

Was your husband, a friend or a relative required to miss work to help you because of your accident or injury?
YesNo

Are you on Social Security Disability or SSI?
YesNo

If yes, what is the basis of your benefits?

Have you ever filed a lawsuit before?
YesNo

If yes, where and against who? Please provide the name and address.

How did the Caller Hear of US?

Referral, if so, by who?

Who completed this online intake?

First and Last Name of Person Completing Form:

*Required fields

While we are honored that you are submitting this online intake this is no intended to engage you into an attorney-client relationship with our firm. We only consider you to be a client after we have received a signed contract, whether it is signed in person or electronically.