Veteran Intake & Clinical Strategy Profile
Submission Type - Please make a selection prior to filling out form
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Initial Intake (I am starting my Medical Record Review)
Additional Document Upload (I have already completed my intake and need to add more files)
Wix Order Number ex: #12345
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Wix Order Number (Required – from your purchase confirmation email)
Veteran Profile
SECTION 1 - PERSONAL & SECURE IDENTITY
First Name
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Enter your First name exactly as it appears on your VA records.
Last Name
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Enter your last name exactly as it appears on your VA records.
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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/
Month
/
Day
Year
Date
Last 4 of your SSN (for identity verification only)
*
SECTION 2: MILITARY CONTEXT AND EXPOSURE
Details regarding your job and locations of service to help us identify potential exposures.
Branch of Service
Military Occupational Specialty (MOS / AFSC / Rate)
e.g., 11B Infantryman, 92G Food Service Specialist
Deployments & Locations (List any locations in Southwest Asia, Iraq, or Afghanistan. This is critical for PACT Act/TERA exposure analysis)
Deployment Exposure Type (multi-select)
Southwest Asia Theater of Operations (1990 – Present)(Includes Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, UAE, Oman, Persian Gulf, Red Sea, Arabian Sea)
Afghanistan (2001 – Present)
Iraq (2003 – Present)
Gulf War Era Service (August 2, 1990 – Present)
Burn Pit / Airborne Hazard Exposure (Post-9/11 Era – 2001 to Present)
Other Toxic Exposure Risk Activities (TERA) (Any Service Period)(e.g., chemicals, solvents, radiation, occupational hazards)
Combat
Noise
None
Unsure
Section 3: Current VA Status
Current VA Disability Rating
Please Select
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Currently Service-Connected Conditions (The "Wins")
Denied Conditions (The "Losses")
SECTION 4: CLAIM STRATEGY & GOALS
Tell us exactly what you want to achieve with this review.
What conditions are you wanting to connect?
SECTION 5: DOCUMENT UPLOADS
Administrative Documents
DD-214 / DISCHARGE PAPERWORK
Browse Files
Drag and drop files here
Choose a file
Upload your discharge papers
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VA Decision/Denial Letters
Browse Files
Drag and drop files here
Choose a file
Any letters where the VA previously denied or rated your claims.
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of
Service Treatment Records (STRs)
Military Medical Records (STRs)
Browse Files
Drag and drop files here
Choose a file
Upload your sick call slips, entrance/exit exams, and in-service treatment records.
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of
Post-Service / Private Records
VA and Private Medical Records
Browse Files
Drag and drop files here
Choose a file
Upload recent treatment notes, specialist reports
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Supporting Evidence
Personal Statements, Buddy Statements, Private Nexus Letters / DBQ ect
Browse Files
Drag and drop files here
Choose a file
Cancel
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SECTION 6 - ADDITIONAL NOTES
Any additional information you would like the provider to know
*****IMPORTANT NEXT STEP****
After submitting this form, you will be automatically redirect to schedule your Zoom Consultation. Your intake process is not complete until your appointment is scheduled.
*****WHAT HAPPENS NEXT****
After submission, our team will review your additional records and determine the next steps.If anything further is needed, we will contact you directly.
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