Law Firm Intake Form
For Retained Expert Work
Patient FIRST Name
*
Patient LAST Name
*
Patient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
example@example.com
Patient Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Birth Gender
*
Male
Female
Other
Patient is:
*
Left Handed
Right Handed
Handedness unknown
Smoker?
*
Patient IS NOT a smoker
Patient IS a smoker
Unknown if patient smokes
Patient Claustrophobia
Is Claustrophobia
Is Not Claustrophobia
Claustrophobia Unknown
Other known health issues?
Case Information
Date of Injury
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is this a Medical Malpractice Case?
*
No
Yes
Type of Work to be performed:
*
Comparison Reading of Prior Imaging
Second Opinion Reading
Initial Reading Requires a more detailed analysis
Biomechanical Analysis
Deposition
Trial
Date and Type of all Radiology Scans (PRE and POST accident)
*
Please be specific
Imaging Transfer
I have a link for you to download the patient imaging.
I can upload the patient imaging to your portal.
I need to order new imaging for this patient.
I need to get back to you on this patient's imaging.
Please paste the link to obtain patient imaging here
Please attach and and all Radiology Reports, Clinical Notes, Medical Records, etc.
*
Browse Files
Drag and drop files here
Choose a file
These are supporting documents only. Not images.
Cancel
of
Report Requested Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Disclosure Deadline
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Legal Information
Law Firm
*
Attorney Name
*
Attorney Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Attorney Email Address
example@example.com
Insurance Information
Insurance Company
Claim Number
Name of Adjuster
Please provide if known
Adjuster Contact Info
Please provide email or phone #
Please take a moment to provide detailed information regarding the accident.
*
This information will certainly aid Dr. Ugorji in his assessment.
Please provide specific detail as to what you would like Dr. Ugorji to focus on.
*
Your Email Address
For confirmation receipt
Today's Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Name
URC Admin Email
example@example.com
URC Company Name
Please verify that you are human
*
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