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?

    Personal Injury Intake Form -Stanley Law Offices
    Personal Injury Intake Form -Stanley Law Offices