Personal Injury Intake Form

Full Name

Address

City

State

Zip

Date of Birth

Email Address

Home Phone

Business Phone

Cellular or Page:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address

City

State

Zip

Email Address

Date of Birth

Home Phone

Business Phone

Cellular or Pager:

Facsimile

Describe the Injury:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?

YesNo

If "Other," was this a road accident?

YesNo

If no, did the injury occur on another's property?

YesNo

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?

YesNo

If yes, what are the witnesses names/contact information?

Were others involved or injured at the same time?

YesNo

If yes, what are their names/contact information?

Was there a police report?

YesNo

Did the injured person receive medical treatment?

YesNo

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?

YesNo

Was the injured person killed as a result of the accident?

YesNo

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

Firm Overview