Injury Intake Form

Your Information

First Name *

Last Name *

Phone *

Email *

Best way to reach you

The Incident

Date of incident

Where did it happen? (city, county)

What happened?

Who do you believe was at fault?

The other party Me Partly both Not sure

Was a police report filed?

Yes No Not sure

Injuries & Medical Care

What injuries did you suffer?

Have you received medical treatment?

ER / hospital Urgent care Primary doctor Specialist / ongoing None yet

Treating doctors, hospitals, or facilities (if known)

Are you still treating?

Yes No

Have you missed work because of the injury?

Yes No N/A

Insurance & Other Info

Your auto or health insurance carrier

Other party's insurance carrier (if known)

Has an insurance company contacted you?

Yes No

Have you already hired or spoken to another attorney?

No Spoke to one, not hired Yes, I have an attorney

Anything else we should know

Got It — Thank You