Client Intake Form

Valor Medical Reviews

Client Intake Form (Screening Questions)
YesNo
YesNo
Psychological (PTSD, Anxienty, Depression, Etc.)Musculoskeletal (Back pain, Knee pain, Shoulder pain, Etc.)Other

Section 1: Case Information
1. Full Legal Name*
2. Date of Birth*

MonthDayYear
3. Preferred Contact Email*
Initial Service ConnectionSecondary Service ConnectionAggravation of Pre-Existing ConditionVA Appeal / Supplemental ClaimOther
5. Condition or Injury Being Reviewed*
Psychological / PsychiatricOrthopedic / MusculoskeletalNeurologicalOther

Section 2: Injury / Condition Summary
7. Brief Summary of Military Service Connection*
Directly related to military serviceSecondary to an already service-connected conditionAggravated by military service
9. Brief Summary of the Injury or Condition*
YesNoUnsure

Section 3: Supporting Documentation Statement

Important: Nexus opinions are strongest when supported by service and medical documentation.

Please review and acknowledge the following statement:

I understand that service treatment records, VA medical records, private medical records, and personal statements significantly strengthen a medical nexus opinion. I acknowledge that submitting relevant records improves the quality and defensibility of the review.
I acknowledge and understand

Section 4: HIPAA-Protected Medical Information
12. Diagnosed Medical Conditions Related to This Claim*
13. Treating Providers or Facilities*
14. Current or Recent Treatment*

Section 5: Record Upload (HIPAA – Secure Submission)

Please upload records using the secure link below. Do not email medical records.

We encourage submission of:
- Service treatment records
- VA decision letters
- VA or private medical records
- DBQs (if applicable)
- Personal statements or buddy statements
16. Upload Supporting Documentation*

Cancelof

Final Acknowledgment

I certify that the information provided is accurate to the best of my knowledge and understand that Valor Independent Medical Reviews, LLC provides independent, conflict-free medical opinions and does not guarantee VA outcomes.
I agree
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