Instructions for Completing the Personal Injury Intake Form

General Guidelines:

1. Provide Accurate Information – Fill out the form as completely and accurately as possible. If a question does not apply to your case, you may leave it blank or mark it as "N/A" (Not Applicable).
2. Be Detailed – When describing the accident and your injuries, include as many details as possible. The more information we have, the better we can assess your claim.
3. Use Additional Pages If Necessary – If you need more space to answer any questions, you may attach additional pages to the form.
4. Gather Relevant Documents– If available, please bring or attach copies of:
   • Police reports
   • Medical records and bills
   • Photos of injuries or accident scene
   • Insurance policies and correspondence
   • Any witness contact information
5. Confidentiality – All information provided in this form is confidential and will only be used for legal representation purposes.

Section-Specific Instructions:

• Client Information: Provide your full name, date of birth, and contact details. Ensure that your phone number and email are correct so we can reach you.
• Accident Details: Include the exact date, time, and location of the accident. Describe what happened in your own words.
• Injury Details: List all injuries sustained and any medical treatment you have received or plan to receive.
• Accident Involvement: If there were other people involved, provide their names and contact details. If a police report was filed, include the report number.
• Insurance Information: Provide your insurance details, as well as any information you have about the other party’s insurance.
• Employment & Financial Impact: If the accident has caused you to miss work or affected your ability to perform your job, please provide details.
• Legal Considerations: If you have consulted another attorney or have pre-existing conditions, please disclose this information.

Final Steps:

• Review your answers for accuracy.
• Sign and date the form where indicated.
• Submit the completed form to our office via email, fax, or in person. If you need assistance filling out the form, please call our office at 833-529-2287.