New Client Intake Form
INSTRUCTIONS:
Welcome to Buckman, Buckman, & Castellano! We are so pleased to serve you as our client. As you work through this intake form please answer all questions truthfully and completely. The information you're entering in this questionnaire is confidential and protected by Attorney-Client Privilege. The information you share will not be disclosed to anyone outside of this office, except in the course of rendering legal services on your behalf, or unless otherwise required by law. Thank you again for trusting us with your case. Don't hesitate to reach out if you have any questions.
Personal Information
Name
*
First Name
Last Name
Other Names by Which You Have Been Known:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What is the best way to contact you?
*
Phone Call
Text
Email
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
State or Country of Birth
*
Driver's License Number
*
Social Security Number
Occupation
*
How did you hear about our office?
*
Background Information
Have you ever been convicted of a felony?
*
Yes
No
Have you ever been convicted of a misdemeanor involving dishonesty, such as fraud or theft?
*
Yes
No
Have you ever been diagnosed with or sought treatment for opiate addiction?
*
Yes
No
Spouse Information
Name
First Name
Last Name
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Names by which spouse is known:
Nickname(s) for Spouse
At-Fault Driver Information (If Known)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Accident Information
Accident Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Day of the Week
*
Time of Accident (am/pm)
*
Where were coming from?
*
Specific Location of the Accident
*
Where were you going?
*
Details of the Accident
Weather Conditions during the Wreck
*
Any construction in the area?
*
Description of Accident
Describe the Accident (Be as detailed as possible.)
*
What was the make, model, and year of the vehicle you were driving?
*
Is this your vehicle, friend's vehicle, a rental or something else?
*
Was anyone, including yourself, to the best of your knowledge, taking any medication or using any sort of drugs?
*
Had anyone, including yourself, been drinking?
*
Were the police called to the scene of the accident?
*
Please Select
Yes
No
Did anyone make a statement at the scene?
*
Please Select
Yes
No
What was said? (Please describe in detail. If nothing was stated, put N/A).
*
Were photographs taken of the scene?
*
Please Select
Yes
No
Were videos taken of the scene?
*
Please Select
Yes
No
Your Car Insurance Coverage
Name of Carrier
*
Policy Number
*
Claim Number (If you haven't opened a claim yet, put N/A).
*
Insurance Coverage for the At-Fault Driver or Company
Name of the Carrier
Policy Number
Claim Number
Your Medical Information
Were you injured in this accident?
*
Please Select
Yes
No
Please describe full details of symptoms and injuries:
*
Did you go to the hospital or urgent care?
*
Please Select
Yes
No
Name of Hospital or Urgent Care
Were you taken by ambulance?
*
Please Select
Yes
No
Are you under the care of a physician now? If so, please name the physician.
*
List doctors, clinics, hospitals for this claim, if any. (Please click "save and add row" to save your entry).
Medical History Questionnaire. Please list all doctors, clinics, and hospitals for the last 10 years. (Please click "save and add row" to save your entry).
*
Have you EVER had prior similar injuries, treated medical conditions and/or symptoms to the same area or current injury? (Please include dates and doctor/facility).
*
Please list any prior claims and/or settlements. (Type of case, dates, attorneys)
*
List any prior injury settlements. (Type of case, dates, attorneys)
*
Are you eligible for Medicare benefits?
*
Please Select
Yes
No
Do you have health insurance? If yes, please send us a copy for our records.
*
Please Select
Yes
No
Thank you so much for taking the time to fill out this document.
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