Intake Form

General

Info

Incident & Injury Details

Employment Details

Insurance

Info

Email

Phone

First Name

Last Name

Case Type

Motor Vehicle Accidents
Premises Liability/Slip & Fall
Dog Bite
Other Personal Injury
Workers' Compensation
Medical Malpractice
Other
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Best Form of Contact

Phone
Text
Email
In Person
Other
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Date Of Birth

SSN

Address

City

State

Postal Code

Pronouns

He/Him
She/Her
They/Them
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Salutation

Mr
Mrs
Ms
Dr
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Date of Incident

Property Damage Amount

Police Investigated

Yes
No
Unsure / I Don't know
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Vehicle Location

Witness 1 Name

Witness 1 Phone

Location

Incident Notes

Hospital/Emergency Name

Hospital/Emergency Dates

Hospital-In Patient

Yes
No
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Taken by Ambulance

Yes
No
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Prior Injuries

Follow-Up Treatment

Employer

Address (EI)

City (EI)

State (EI)

Days Missed

Wage

Lost Wage Claim

Hrs/Wk

Returned to Work

Yes
No
Unsure/I don’t know
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Insurance #1

Insurance #2

Defendant #1

Defendant #2

Insurance Amount

Group Health Insurance

Plaintiff’s Auto Insurance

Contacted by Defendant’s Insurance

Yes
No
Unsure/I don’t know
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Liability ONLY

Yes
No
Unsure/I don’t know
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Offer Made

Yes
No
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Med Pay

Yes
No
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Medicare

Yes
No
Unsure/I don’t know
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Medicaid

Yes
No
Unsure/I don’t know
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