Date:

Referral Source:
Type of Case:
Date of Incident/Injury:
Client Name:
Address:
City/State: Zip:
Telephone No: (H) (W)
Social Security No:
Date of Birth: (Client)
Employer:
How Long:
Level of Education:
Marital Status: Spouse's Name:
Spouse's phone no.:
Children? Yes No
If yes, names and ages:
Relative or Acquaintance Contact:

Circumstances of Incident:

Defendant Health Care Provider(s):
#1:
#2:
#3:
#4:

Health Care Provider is rendering treatment as of the date of intake: Yes No

Client has supplied medical records and/or X-ray films at first meeting: Yes No

Obtained signed medical release authorization form from client: Yes No

Firm shall assume responsibility for obtaining all medical records: Yes No

Prior medical history:

Medical records to be obtained from:
1.)
2.)
3.)

Client follow-up:
Obtain medical records Yes No
Confer with family regarding pursuing claim Yes No
Forwarding medical records to this office Yes No

Requesting medical records from:
1.)
2.)
3.)

Accept Investigate Reject

Reason if rejected:

Date of rejection:

You've completed the form!
Click on "Submit" when ready to send.