JustUs Law Firm Client Intake Form

JustUs Law Firm Client Intake Form

Personal Injury
Basic Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date

MonthDayYear
Social Security Number
Driver's License Number
Emergency Contact
*You consent to this person being contacted about your case
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status
Spouse's Name
Were you employed at the time of the incident?
If so, what is your Employer's name, address and phone number
YesNo
If so, how much time have you missed?
Incident Information
Please provide a summary of what happened including the date and location of the incident. If the police were called please provide the police department, case number, and other driver's information. Also include the make, model, and year of your vehicle.
Were there any additional passengers in the vehicle with you when the accident occurred?
Please provide their name and contact details
Please provide the other driver's contact details below if you obtained them.
If you have photos from the accident, please provide them here:

Cancelof
Medical Treatment
YesNo
If so, please provide the name of the Hospital
Were you transported by ambulance?
If so, please provide the name of the Ambulance Service
List all injuries resulting from the accident
Were X-Rays performed?
Have you had any additional treatment? Such as seeing a chiropractor or had an MRI
Chiropractor's Name
Date of 1st Visit
Date of Last Visit
Primary MDs Name
Date of 1st Visit
Insurance Information
Please provide the name of your vehicle's insurance company and your policy number. If you've been provided a claim number provide it below.
If you have health insurance please provide your insurance carrier, member ID, and any claim numbers related to this accident.
Additional Information
Did you have any prior injuries before this accident?
If so, please describe them below
Have you had any prior legal issues? Such as back child support, filing for bankruptcy, or criminal charges.
If so, please provide the details below
Any additional information that may be relevant:
Should be Empty:

JustUs Law Firm Client Intake Form

Basic Information

Incident Information

Medical Treatment

Insurance Information

Additional Information