Fill and Sign the How to Get Full Compensation for Lost Income After an Injury Form

WAGE AND INCOME LOSS NAME OF CLIENT:______________________________________ Please keep an accurate record of time you lost from work as a result of your accident; amount you were paid by your employer or others; the reason for your absence. Do not subtract taxes, etc. from amount of income lost.DATE REASON AMOUNT PAIN AND DISCOMFORTNAME OF CLIENT:______________________________________On first signs of pain or discomfort, call your doctor and follow his instructions. Do not exaggerate or minimize complaints. Explain your complaints fully and record the appropriate information below.DATE COMPLAINT Rx TAKEN HOSPITAL EXPENSESNAME OF CLIENT:______________________________________ Include all medical bills no matter how small. The total of the bill, even if insurance company, etc. has paid part or all of it, should be included. Ask for a bill when you leave the hospital.DATE HOSPITAL NAME DOCTORS DATE ADMITTED DISCHARGE AMOUNT AND ADDRESS NAME OF CLIENT:_______________________________________Enter each visit to doctor, home visit or hospital call. Enter total amount from doctor bill. Keep parking lot and taxicab receipts. If you use your car, keep round trip mileage.MODE OF DOCTOR'S NAME DATE TRANSPORTATION AND ADDRESS TREATMENT TOTAL BILL PHYSIOTHERAPYNAME OF CLIENT:_______________________________________Enter all dates on which you have therapy treatments at home or office. Keep all receipts for taxi and parking lot. If you use your car, enter round trip mileage.MODE OF DOCTOR'S NAME DATE TRANSPORTATION AND ADDRESS TREATMENT TOTAL BILL NAME OF CLIENT:_______________________________________Enter all prescription and non-prescription drugs, bandages, etc.PHARMACY BY DRUG TOTAL DATEAND ADDRESS DOCTOR NAME Rx NO. DOSAGE BILL MISCELLANEOUS EXPENSESNAME OF CLIENT:_______________________________________Keep all sales receipts for everything that pertains to your case. Enter expenses for ambulance, nurses, domestic help, personal property loss, etc. DATE EXPLAIN TOTAL BILL