• Attorney/VSO Veteran Intake Form

    Please help your veteran client complete this secure intake form so we can review their claim and supporting records.

  • Veteran Information

    Basic personal and contact details for the veteran client.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender

  • Attorney/VSO Referral Details

    Tell us who is referring the case and how to reach them if needed.
  • Are you the VA Accredited Attorney or VSO representing the veteran?*
  • Format: (000) 000-0000.
  • Are the veteran’s records available?*

  • MOS

    Military occupational details

  • Dates of Service

    Service date information
  • Start Date of Service*
     - -
  • End Date of Service*
     - -

  • Deployment

    Deployment details

  • TERA Questions

    Toxic exposure and risk activity questions
  • Is the veteran claiming any conditions related to Toxic Exposure Risk Activity (TERA)?*
  • Any Non-Deployment Toxic Exposure Risk Activity (TERA) Related to MOS/AFSC/NEC?*
  • Did the veteran serve in any of the Gulf War hazard locations? Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan; Israel; Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; and the Red Sea.
  • Did the veteran serve in any of the following herbicide locations? Republic of Vietnam to include the 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include repeated operations and maintenance with) a C-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves).
  • Has the veteran been exposed to any of the following?

  • Claimed Conditions

    Medical conditions and claim description
  • Type of Claim*

  • Homeless

    Housing status
  • Is the veteran homeless*

  • HIPAA

    Secure upload and acknowledgment
  • Authorization and AcknowledgmentBy submitting this form, I represent that I am authorized by the claimant/veteran to disclose to Dr. Kenneth Hammonds and/or Professional Medical Services any records, reports, and other information submitted in connection with the claimant’s case for purposes of medical-legal review, evaluation, consultation, and preparation of reports or opinions. I understand that this submission does not, by itself, authorize Dr. Kenneth Hammonds and/or Professional Medical Services to obtain records directly from healthcare providers unless a separate authorization, signed by the claimant/veteran, is provided.*
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