Intake Forms – Turner & Bowerman, LLC

Client Intake Forms

PERSONAL INJURY CLIENT INTAKE FORM

First Name(Required)

Middle Name(Required)

Last Name(Required)

DOB(Required)

SSN:(Required)

Address:(Required)

Phone:(Required)

Email(Required)

Best Method of Contact:(Required)

Marital Stat:(Required)

Children Names/Ages

Employer:(Required)

Vehicle Make/Model/Vin:(Required)

Itemized Property Damage (ex. Cell phone shattered, child seat, etc.. – Please list model # and price):(Required)

What date did the accident/injury occur?(Required)

Where did the injury occur?(Required)

Was this a work related accident?(Required)

Describe how the injury/accident occurred:(Required)

Who do you believe is responsible for your injuries?(Required)

Did the police respond to the scene? Ambulance? Fire department? Which department?(Required)

Do you have photos/videos of the property damage, or photos of any documents you received from the police or medical providers (ex. Police Report Card with Case ID)? If so, please upload them here:

Drop files here or

Max. file size: 512 MB.

Was anyone cited by police? Who?(Required)

If you didn’t go in an ambulance to the hospital/ER immediately, did you seek medical attention? If so, please list the name of the facility and the date you went for treatment:(Required)

Please describe all of your injuries:(Required)

List all doctors and healthcare providers that have treated you for injuries, listing the name of the clinic(s)/hospital(s)/doctor(s), addresses, and telephone numbers if possible:

(1)

(2)

(3)

(4)

What are your approximate total medical expenses to date?(Required)

What are your approximate future medical expenses?(Required)

List all insurance companies that may be involved, including phone numbers (Please upload photos of your ID cards (Front AND Back) if possible:

1. At-Fault Auto Insurance:(Required)

2. Your Auto Insurance:(Required)

3. Your Health Insurance:(Required)

4. Other (Disability, etc.):(Required)

Please provide photos of your health insurance ID card(s) here - PLEASE PROVIDE PHOTOS OF THE FRONT AND BACK OF EACH CARD

Drop files here or

Max. file size: 512 MB.

Did you lose any income as a result of the injury?(Required)

If so, how much? Please give specific information on shifts missed, hourly pay rate, employer, job title, reduced ability to perform tasks or work, etc.:(Required)

Are you still in pain from the accident? If so, please describe:(Required)

Has your life changed in any other way? Are you unable to do things you used to enjoy before the accident?(Required)

If you are married, has your spouse experienced any loss as a result of your injury?(Required)

Were there any witnesses to your accident? If so, please give their information:

(1)

(2)

(3)

(4)

Have you already spoken with another attorney about this case? If so, please give their name and contact information.(Required)

Are you still working with this attorney?(Required)

Has an attorney previously declined to represent you in this matter? If yes, why?(Required)

Please provide information on any other auto accident, slip-and-fall, or worker’s comp case you have been involved in (including year/county of injury, injuries received, which law firm you used to represent you, and the amount of settlement, and the doctor(s) you treated with):

(1)

(2)

(3)

(4)

I DECLARE UNDER PENALTY OF PERJURY THAT I PERSONALLY ANSWERED THE ABOVE QUESTIONS TRUTHFULLY AND ACCURATELY TO THE BEST OF MY KNOWLEDGE. I ACKNOWLEDGE THAT FAILURE TO PROVIDE TRUTHFUL RESPONSES MAY NEGATIVELY IMPACT MY CASE(Required)