Veterans Registration Form

Veterans Claims Assistance

INTAKE FORM
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SSN
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Branch of Service
Rank
Date of Enlistment

MonthDayYear
Date
Date of Discharge

MonthDayYear
Date
Are you a Purple Heart recipient?

YesNoOther
Are you receiving VA benefits?

YesNoOther
Service Number/VA File Number:
Service-Connected Disabilities:
List disabilities/conditions that are currently service connected (if any).
Did you receive a VA disability rating?

YesNo
If yes, what is your current rating?
CLAIMS INFORMATION
Type of Claim:
Claim Status:
Date of Last VA Decision (if applicable):

MonthDayYear
Date
Current Disability(ies) You Wish to File a Claim For:
Have you filed for any previous claims?

YesNo
If yes, provide details (date, type of claim, outcome).
MEDICAL AND TREATMENT INFORMATION
Have you received medical treatment for your service-related conditions?

YesNo
Please provide details of any medical treatment related to your claims (Doctors, Hospitals, Dates, etc.):
Do you have any medical records related to your service-connected condition(s)?

YesNo
If yes, please attach or provide access to records.

Pkease attach records
Cancelof
SUPPORTING DOCUMENTS
Please attach the following documents (if applicable):
DD-214 (Discharge papers)
VA Rating Decision Letter
Medical Records related to claim
Previous Claim Forms and Documents
Please upload the supporting documents:

Cancelof
ADDITIONAL INFORMATION
Do you require assistance with completing forms?

YesNo
Are there any specific issues or concerns you want to address regarding your claim?
How did you hear about our VA Claims Assistance services?
Please provide any additional information or comments
SIGNATURE & CONSENT

By signing below, I authorize the release of any necessary medical and service-related information for the purpose of assisting with my VA claims.
Signature

Powered by Jotform SignClear
Today's Date

MonthDayYear
Date
Should be Empty:

Veterans Claims Assistance