Client Personal Injury Intake Form

NewPersonal
New Client Client Intake

InjuryForm
Intake Form
I. Client Information:
Date:
Full Legal Name:
Address, City , State , Zip:
E-mail:
Home Phone:
Cell Phone:
Work Phone:
II. Personal Information:

Marital Status Single Married Divorced
Widow
Spouse's Name/Significant Other:
Children/Names/Ages:
Drivers License Number:
Date of Birth:
Referred by:
Social Security Number:
Name of Emergency Contact:
Relationship:
Emergency Contact Information:

II. Personal
II. Personal Information
Information Continued:
Continued:
Prior Criminal
Prior Criminal Record?
Record?Y ?Yes
Yes No
No
Explain:
Explain:
Prior Traffic
Prior Traffic Citations?
Citations?Y ?Yes
Yes No
No
Explain:
Explain:
Do You
Do You Use
Use Social
Social Media?
Media ?Y ?Yes
Yes No
No
List and
List and and
and all,
all, i.e.
i.e. Facebook,
Facebook,
Twitter, etc.:
Twitter, etc.:
III. Accident
III. Accident Information:
Information:
Date of
Date of Accident:
Accident:
Statue of
Statue of Limitations:
Limitations:
Time Of
Time Of Accident:
Accident:
Location:
Location:
How did
How did the
the accident
accident happen?
happen?
Passengers in
Passengers in vehicle?
vehicle?
Investigated by
Investigated by Police?
Police? Yes
Yes Accident Report
Accident Report Yes
Yes
No
No Obtained?
Obtained? No
No
Incident Number:
Incident Number:
Statements given
Statements given to
to anyone:
anyone:Y :Yes
Yes No
No
To whom?
To whom?
Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

50 Penn Place 1900 NW Expressway, Suite 501 Oklahoma City, OK 73118
III. Accident Information Continued:
Tickets or Citations Issued? Yes No
To Which Party?
Ticket or Citation Number:
IV. Injuries:
Injuries Sustained in this Accident:
Prior Injuries:
Pre-Existing Conditions:
Medical Conditions/Diseases:
V. Client's Insurance Information:

Insurance Company:
Agent's Name:
Address:
Phone Number:
Fax Number:
E-Mail
Policy Number:
Claim Number:
Liability Coverage: Yes If so , how much?

No

V. Client's Insurance Information Continued:
Under/Uninsured Coverage: Yes If so, how much?
No
Medical Payment/Med-Pay: Yes If so, how much?

No
Collision: Yes If so, how much?

No
Rental: Yes If so,

No how
much?
Claims Adjuster:
Address:
Phone Number:
Fax Number:
E-Mail
Med-Pay Adjuster:
Address:
Phone Number:
Fax Number:
E-Mail:
VI. Client's Insurance Information 2:

(Please complete for each insurance policy (commercial or personal) which insures any
vehicle owned by you or anyone in your household.)
Insurance Company:
Agent's Name:

VI. Client's Insurance Information 2 Continued:
Address:
Phone Number:
Fax Number:
E-Mail
Policy Number:
Claim Number:

No

No

No

No
Rental: Yes If so, how much?

No
Claims Adjuster:
Address:
Phone Number:
Fax Number:
E-Mail
Med-Pay Adjuster:
Address:
Phone Number:
Fax Number:

VI. Client's Insurance Information 2 Continued:
E-Mail:
VII. Client's Vehicle Information:

Year:
Make:
Model:
Color:
Mileage and General Vehicle

Information:
Name of Towing Company:
Do you Own Any Other Vehicles? Yes No

(Car, Truck, RV, Motorcycle)
If you answered yes, please provide the following information for each
vehicle:
Insurance Information:
Insurance Company:
Agent's Name:
Address:
Phone Number:
Fax Number:
E-Mail
Policy Number:
Claim Number:

No

VII. Clients Vehicle Information Continued.
No

No

No

No
Does a Family Member in Your Yes No

Household own a Vehicle?
If you answered yes, please provide the following information for each
vehicle:
Insurance Information:
Insurance Company:
Agent's Name:
Address:
Phone Number:
Fax Number:
E-Mail
Policy Number:
Claim Number:

No

No

VII. Client's Vehicle Information Continued:
No

No

No
VIII. Client's Health Insurance Information:

Name of Insured:
Insurance Company
Address:
Phone:
Policy Number:
Group Number:
Identification Number:
Type of Coverage:
Medicare: Yes No
Medicare Number:
Medicaid Yes No
Medicaid Number:
IX. Medical Treatment Information:

(Please list all doctors including Ambulance and ER visits since the date of the accident)
Ambulance? Yes No
Name of Ambulance Service:

IX. Medical Treatment Information Continued:
Do You have Copies of Medical Yes No
Bills and Records?
Emergency Room? Yes No
Name of Emergency Room?
Who has paid your medical bills?
Medical Providers (Doctors, Physical Therapy, Chiropractor, MRI, etc...):
Medical Facility 1:
Treating Physician /Physical

Therapist/ Chiropractor:
Dates of Service:
Facility Address:
Phone Number:
Fax Number:
E-mail:
Medical Facility 2:

Dates of Service:
Facility Address:
Phone Number:
Fax Number:
E-mail:
Medical Facility 3:


IX. Medical Treatment Information Continued:
Dates of Service:
Facility Address:
Phone Number:
Fax Number:
E-mail:
Medical Facility 4:

Dates of Service:
Facility Address:
Phone Number:
Fax Number:
E-mail:
Medical Facility 5:

Dates of Service:
Facility Address:
Phone Number:
Fax Number:
E-mail:

X. Property Damage Information:
Property Damage Already Yes Do You have and Yes
Collected on Your Vehicle? No Estimate for No
Property
Damage?
Do You have Pictures of Your Yes No

Vehicle?
XI. Lost Wages:

Did you Miss Work as a Result of Yes No
this Accident?
Employer:
Contact Name & Phone Number:
If so, who can verify your lost

wages?
Rate of Pay: Paid how

Often?
XII. Defendant's Insurance Information:

Is there more than one defendant? Yes No
If so, please enter all of the
following information for each
defendant.
Defendant 1
Defendant's Insurance Company:
Policy Number:
Claim Number:
Full Legal Name:

XII. Defendant's Insurance Information Continued:
E-mail:
Home Phone:
Cell Phone:
Work Phone:
Date of Birth:
Name of Owner of Vehicle: (if

different from driver)
Relationship Between Driver and Employer-Employee

Owner: Parent-Child
Family
Friend
Other
Bodily Injury Adjuster's Name:
Address:
Phone Number:
Fax Number:
E-Mail:
Property Adjuster's Name:
Address:
Phone Number:
Fax Number:
E-Mail:

Any Additional Notes or
Information:
Defendant 2
Defendant's Insurance Company:
Policy Number:
Claim Number:
Full Legal Name:
E-mail:
Home Phone:
Cell Phone:
Work Phone:
Date of Birth:
Name of Owner of Vehicle: (if

different from driver)
Relationship Between Driver and Employer-Employee

Owner: Parent-Child
Family
Friend
Other
Bodily Injury Adjuster's Name:
Address:
Phone Number:

Fax Number:
E-Mail:
Property Adjuster's Name:
Address:
Phone Number:
Fax Number:
E-Mail:
Any Additional Notes or

Information:
Other Important Information and

Notes:

Copies to Bring with You Drivers License
Health Insurance Card
Car Insurance Card
Declarations Sheet
Medical Records
Medical Bills
Photographs of Client Vehicle
Photographs of Defendant Vehicle
Photographs of Injuries
Disclaimer: The submission of information does NOT establish an attorney-client

relationship. This form is for case evaluation purposes. Please contact attorney's office.
if you would like to discuss hiring/retaining an attorney.


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NewPersonal

New Client Client Intake

Full Legal Name:

Address, City , State , Zip:

II. Personal Information:

Spouse's Name/Significant Other:

Drivers License Number:

Social Security Number:

Name of Emergency Contact:

Emergency Contact Information:

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Ticket or Citation Number:

V. Client's Insurance Information:

Liability Coverage: Yes If so , how much?

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Medical Payment/Med-Pay: Yes If so, how much?

Collision: Yes If so, how much?

Rental: Yes If so,

VI. Client's Insurance Information 2:

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Liability Coverage: Yes If so , how much?

Under/Uninsured Coverage: Yes If so, how much?

Medical Payment/Med-Pay: Yes If so, how much?

Collision: Yes If so, how much?

Rental: Yes If so, how much?

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

VII. Client's Vehicle Information:

Mileage and General Vehicle

Name of Towing Company:

Do you Own Any Other Vehicles? Yes No

Liability Coverage: Yes If so , how much?

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Medical Payment/Med-Pay: Yes If so, how much?

Collision: Yes If so, how much?

Rental: Yes If so, how much?

Does a Family Member in Your Yes No

Liability Coverage: Yes If so , how much?

Under/Uninsured Coverage: Yes If so, how much?

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Collision: Yes If so, how much?

Rental: Yes If so, how much?

VIII. Client's Health Insurance Information:

IX. Medical Treatment Information:

Name of Ambulance Service:

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Emergency Room? Yes No

Name of Emergency Room?

Who has paid your medical bills?

Medical Providers (Doctors, Physical Therapy, Chiropractor, MRI, etc...):

Treating Physician /Physical

Treating Physician /Physical

Treating Physician /Physical

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Treating Physician /Physical

Treating Physician /Physical

Ph. 405.471.2224 F. 405.810.9901 Website. farhalawfirm.com Email. nick@farhalawfirm.com

Do You have Pictures of Your Yes No

XI. Lost Wages:

Contact Name & Phone Number:

If so, who can verify your lost