Who is you primary care physician?
If Homeowners Claims:
The Crash / Property Damage:
Position / activity before impact (neck turned/hands on wheel/drinking water/etc)?
Position / activity during impact (hit head/wrist buckled/etc)?
Feelings/emotions/pain immediately after crash:
Symptoms, pain and current injuries:
How has this impacted daily life / activities client cannot do or has pain with / etc:
Things not able to do anymore with friends, spouse, kids anymore (if applicable):
Have your injuries affected your spouse or kids?:
List Prior/Current Treatment Facilities:
Do you consent for our firm to order all of your treatment records and billing, which may include signing on client’s behalf?
If yes, when? With which insurance company? Did you hire a lawyer? When was this claim resolved?