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Client Intake Form – Personal Injury
Personal Injury Client Intake Form
Contact /Personal Information
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Case/Background Information
Cause of Injury
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Car Accident
Wrongful Death
Bicycle Accident
Pedestrian Accident
Motorcycle Accident
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If other, what caused your injury?
Date of Injury
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MM slash DD slash YYYY
If the accident/injury occurred more than 3 years ago, you may not be able to proceed with a personal injury claim.
Are you at fault for the accident/injury?
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No, I am NOT at fault
I am PARTIALLY at fault
I am AT FAULT
If the accident/injury you sustained was your fault, then this will be an impediment to recovery. However, if you were only partially at fault, you may still be entitled to compensation.
What City/County did the injury occur in?
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Where did the injury occur specifically?
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Name of streets, intersection, etc.
How did the injury/accident occur?
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Please briefly describe what/who caused the injury/accident
Extent of Injuries
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Please describe the injuries you have sustained
Have you been treated by a medical professional for your injuries?
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Yes
No
If Yes, please briefly describe the treatment you have received thus far
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