Fill and Sign the Medical Mal Practice Intake Sheet Initial Client Statement Form

- 1 - PERSONAL INJURY INTAKE SHEET PERSONAL INFORMATION Client's Name Aliases Date Address Phone H W SSN Race Sex Age DOB Marital Status M S D Resides With List addresses where client has resided during the past 10 years and period of time at each residence Address From To EDUCATION Educational background, listing names of schools attended, addresses, years attended and any degrees obtained Name & address of school Years attended Degree CHILDREN Child(ren) Name(s) Age Date of Birth Father’s Name Address Phone H W Employer Position Held Employer’s Address - 2 - Mother’s Name Address Phone H W Employer Position Held Employer’s Address If client is acting on behalf of a deceased relative, list the names, addresses, telephone numbers and relationships to decedent of the decedent's immediate family Name Address Telephone Relation Name Address Telephone Relation Name Address Telephone Relation Name Address Telephone Relation Spouse’s Name Is your spouse employed? Yes No If so, indicate Employer's name Telephone Address of spouse's employer Present rate of pay $ per week month year Average yearly income of spouse $ How long with this employer? List spouse's employment history for past five years Name of employer Addres s Period of employment From To Position Salary $ - 3 - Reason for leaving Name of employer Addres s Period of employment From To Position Salary $ Reason for leaving Name of employer Addres s Period of employment From To Position Salary $ Reason for leaving Name of employer Addres s Period of employment From To Position Salary $ Reason for leaving EMPLOYMENT INFORMATION Name of employer (if unemployed, last employer) Address of employer Telephone number Personnel Director/Supervisor Job title/type of work Present rate of pay $ Per Week Month Year Hours worked each week Do you regularly work overtime? Yes No If so, indicate approximate amount of time & rate of pay Hours Rate of Pay Do you receive tips or other type of income? Yes No If so, indicate - 4 - Type of income Amount Per week/month/year $ $ $ $ When did you first begin working for this employer? If unemployed, when did you leave this employer? Reason for leaving What was your reported income in the year before your accident? $ Were you working for your employer at the time the injury occurred? Yes No Did you applied for worker's compensation benefits because of your accident? Yes No If so, indicate the amounts paid to or received by you to date $ State your employment history for past ten years Name of employer Address Period of employment From To Position Salary $ Reason for leaving Name of employer Address Period of employment From To Position Salary $ Reason for leaving Name of employer Address Period of employment From To Positio n Salary $ Reason for leaving Name of employer Addres s Period of employment From To Position Salary $ Reason for leaving - 5 - POLICE RECORD Have you ever been convicted of a felony? Yes No If so, describe as follows Place Charge Result Date of conviction Place Charge Result Date of conviction Place Charge Result Date of conviction Is there now, or has there ever been, a restriction on your driver's license? Yes No If so, describe the details of such restriction CLAIMS AND LAWSUITS Have you ever been involved in any claim or lawsuit, excluding divorce? Yes No If so, list below every claim you have made for money or lawsuits in which you have ever been involved Date Place Against whom Nature of claim Result Date Against whom Nature of claim Result Date Against whom Nature of claim Result - 6 - INSURANCE INFORMATION Name of insurance company Address Adjuster's name Telephone Policy number Policy limits $ Do you have insurance covering damage to your car? Yes No Deductible amount $ How much does your insurance cover if you hurt someone else with your car? $ Uninsured motorist policy limits $ Med Pay Amount $ Do you have a second uninsured motorist policy? Yes No If so, fill in the following Name of second insurance company Address Adjuster's name Telephone Policy number Policy limits $ Do you have health or accident insurance? Yes No If so, indicate Name of health insurance company Policy # Address Insurance agent's name Telephone Name of accident insurance company Policy # Address Insurance agent's name Telephone Have you ever had insurance of any kind declined or cancelled? Yes No If so, give reason MEDICAL HISTORY BEFORE ACCIDENT Have you been hospitalized at any time before this accident? Yes No - 7 - If so, list below all hospitalizations Date Name of Hospital and Doctor Duration Nature of illness Have you had any physical examinations before this accident? Yes No If so, list below all physical examinations for five years before this accident Date Name of Doctor and Address Purpose Have you had any accidents or injuries before this accident? Yes No If so, list below every such accident or injury and whether there was a claim for damages or not Date Place Nature of accident/injury Name of treating physician Claim? Yes No Date Place Nature of accident/injury Name of treating physician Claim? Yes No Date Place Nature of accident/injury Name of treating physician Claim? Yes No - 8 - Have you had any chronic illnesses or diseases before this accident? Yes No If so, list every such illness or disease suffered in the five years before this accident Have you had any other chronic health problems or disabilities? Yes No If so, list them below Did you use any drugs or medication regularly before the accident? Yes No If so, list the type of drug and reason for use Have you ever had any broken bones? Yes No If so, give date and circumstances Date Circumstances MILITARY BACKGROUND Were you in the military service? Yes No Branch of service Dates from to Type of discharge Any service-connected injuries? Yes No If so, describe details - 9 - Have you received or do you receive payments from VA, social security or other source? Yes No Claim number FACTS OF THE ACCIDENT Date Day Time Weather conditions Were seat belts in use in your vehicle? Yes No If so, who in your vehicle was using a seat belt and who was not using a seat belt? Were police called to the scene of the accident? Yes No If so, did the police take photographs of the accident scene? Yes No If so, which police department has possession of such photographs? Describe what happened DIAGRAM Indicate on a diagram in the space below what happened. Write in street or highway names or numbers and show direction of travel by arrows. Also, show north by putting an arrow in a circle - 10 - FACTS CONCERNING THE DEFENDANT - (person responsible for accident) Full name of defendant Address Name of defendant's employer Name of defendant's spouse Name of defendant's insurance company Address Adjuster's name Phone Policy No. Claim No. Policy limits $ Do you know what the defendant's financial circumstances are, excluding any insurance coverage? If so, specify Give your observations about the defendant as a person Name of 2nd person responsible for accident - 11 - Address Name of 2nd person's insurance company Address Adjuster's name Phone Policy No. Claim No. Policy limits $ Name of 3rd person responsible for accident Address Name of 3rd person's insurance company Address Adjuster's name Phone Policy No. Claim No. Policy limits $ OTHER INJURED PARTIES Were other parties, other than the defendant, injured in this accident? Yes No If so, indicate the following Name of 2nd injured party: (2nd plaintiff) Address Relationship to you Telephone number Birthdate Name of 3rd injured party: (3rd plaintiff) Address Relationship to you Telephone number Birthdate WITNESSES TO THE ACCIDENT List the names, addresses, and telephone numbers of all witnesses to the accident, and any other persons who may be of assistance in testifying about your case, your injuries or changes in your activities since the accident Name of 1st witness Address Telephone Age Employment Nature of testimony - 12 - Name of 2nd witness Address Telephone Age Employment Nature of testimony Name of 3rd witness Address Telephone Age Employment Nature of testimony STATEMENTS MADE Have you talked with any police officer, investigator, insurance adjuster or any other person about this incident? Yes No If so, indicate to whom you have spoken, the person's address and telephone number Name Address Telephone Have you given a written or recorded statement to any person about this incident? Yes No If so, answer the following Name of person to whom statement was given Date given If written, do you have a copy? Yes No Persons present at time Did you sign the statement? Yes No Did the defendant make any statement to you or in your presence concerning this incident? Yes No If so, indicate what was said and to whom - 13 - When and where was the above statement made? Date Place List the names and addresses of any persons who may have heard it Name Address Were any statements about the accident made to or taken from anyone else at the scene of the accident? Yes No If so, describe the name of the person from whom the statement was taken, as follows Name Telephone number Nature of statement Were any statements about the accident made to or taken from anyone else at the scene of the accident? Yes No If so, describe the name of the person from whom the statement was taken, as follows Name Telephone number Nature of statement DAMAGES FROM ACCIDENT The amount of recovery made in this case will be affected by the injuries, damages or expenses incurred as a result of your accident. It is important that you fully list all information regarding your injuries and your expenses as a result of this accident. State in full detail all injuries you received as a result of this accident: - 14 - State your present physical condition such as scars, deformities, headaches, etc. Describe "loss of enjoyment of life" by listing what normal activities, including sports, hobbies or other activities you enjoyed before this accident and cannot do now as a result of the accident Activity Times/week prior to accident Times/week after accident Have you missed time from work as a result of your injuries? Yes No If so, indicate the following From To Did you lose wages for the periods of time missed from work due to this accident? Yes No If so, state the total wages lost to date and the dates Wages lost Dates - 15 - Have you had any increases or decreases in your pay since the accident? Yes No If so, explain Did you lose any promotion or merit increase or fringe benefits due to the accident? Yes No If so, describe If self employed, have you had to hire anyone to take your place? Yes No If so, indicate the costs involved If you are a student, indicate time lost from school From To Indicate period of time you were confined to your home From To Indicate period of time you were confined to bed rest From To When is it expected you can return to work? - 16 - List any non-monetary compensation you have lost Have you been forced to borrow any money as a result of your injuries and inability to work? Yes No If so, describe Are you able to work part time? Yes No If so, where or what kind of work could you do? List all hospitals in which you were examined or treated or to which you were admitted as a patient as a result of the injuries sustained in this accident Name of hospital Address From To Total costs $ Name of hospital Address From To Total costs $ Name of hospital Address From To Total costs $ List the full name, address and telephone number of each physician who has examined or treated you for your injuries Doctor's name Telephone Address Specialty Type of treatment - 17 - Doctor's name Telephone Address Specialty Type of treatment Doctor's name Telephone Address Specialty Type of treatment Doctor's name Telephone Address Specialty Type of treatment Have you used any of the following in connection with treatment? Dates From To Wheelchair Back or neck brace/collar Crutches Traction Physical therapy Othe r List all medications which you have taken for injuries, the name of the doctor prescribing each medication and length of time you took the medication Type of medication Prescribing doctor's name Length of time Indicate the amount of all bills/expenses incurred to date as a result of this accident (attach copies of all such bills, whether paid or unpaid.) $ - 18 - Have you sustained any other injuries since this accident? Yes No If so, indicate date, nature of injury and whether you received medical treatment for said injuries Date of injury Nature of injury Medical treatment PROPERTY DAMAGE If your vehicle was damaged and has been repaired, indicate name and address of party who made repairs Name of Person who performed repairs Address Telephone number Have you incurred car rental expenses? Yes No Total Rental Expense $ Where is your vehicle presently located? If any other personal property was damaged, describe said property Total medical & related expenses to date $ Date Total of property damage amount to date $ Date IMPORTANT Please collect and attach copies of all medical and related bills incurred to date as a result of this accident, indicating which have been paid and which are still due. Please be sure to forward copies of all future medical bills, drug/medication bills, etc., As they are incurred, even if paid by insurance. See the following two pages for list of items to provide to your attorney and a list of general instructions that will require your attention. In completing this intake sheet, have you thought of any information which I have not asked which may be of some assistance to me in representing you? If so, state it on the back of this form no matter how silly, trivial or embarrassing it may seem. Client's signature Date - 19 - INSTRUCTIONS TO CLIENT Please be sure to provide me with the following 1. All medical and hospital records 2. Photographs (of scene of accident, of client showing injuries, braces, casts, etc., of automobile or other damaged property) 3. All hospital, medical and related bills, either paid or unpaid (physicians, surgeons, ambulance, hospitals, private nursing care, therapy, drugs/medication, crutches, braces, x- rays, domestic help, car rental, clothing, etc.) 4. Income tax returns for the last five years 5. Your automobile insurance policy or policies 6. Insurance policy that may require aid of attorney to notify and collect (income protection, hospitalization, etc.) 7. Copies of any statements previously made to anyone (opposing side, your insurance carrier, etc.) 8. Repair bill on any damaged property 9. Repair estimates on any damaged property 10. Purchase invoices and estimates of value of personal property damaged or lost in accident (including clothing, jewelry, cameras, and all other property damaged in accident) 11. Correspondence with insurance company, insurance adjusters 12. Business cards from insurance company agents and adjusters, opposing driver, etc. 13. Copy of any accident reports 14. Statement from employer regarding lost wages showing time and wages lost from work 15. Copies of check stubs and/or other records showing hourly rate of pay 16. Copies of any application for other insurance benefits 17. Copy of any application for unemployment benefits 18. Copy of social security card 19. Make copy of current driver's license Please note the following general instructions 1. Do not talk to insurance adjuster 2. Do not discuss the facts of the accident with anyone before having your first conference with the attorney - 20 - 3. Do not sign anything without your attorney's permission 4. Keep a diary of your trips to all doctors, hospitals, therapists and notes of your pain with times and dates 5. Keep all your medicine bottles and containers (as possible evidence at trial) 6. Bring or send all future medical bills to attorney's office 7. When you return to treating physicians for follow- up examinations, be sure to advise them at each examination the nature of all of your continuing problems resulting from the accident 8. Keep a record of all out-of-pocket expenses, including travel expenses for medical treatment 9. Report to your attorney any suspicious actions, such as someone taking pictures, movies, etc. - 1 - EMPLOYMENT CONTRACT AND POWER OF ATTORNEYIN A PERSONAL INJURY CASE THIS AGREEMENT made this date at __________________, ________________, by and between _________________________, Attorney at Law, hereinafter known as ATTORNEY and ____________________________ hereinafter known as CLIENT. WITNESSETH: 1. CLIENT retains ATTORNEY to represent him as his Attorney at Law in a cause of action against _____________________ regarding the following facts, to-wit: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ This contract empowers ATTORNEY to institute such legal action as may be advisable i n his judgment and to compromise and settle the matter at any time, with the consent of the CLIENT , and CLIENT agrees to pay ATTORNEY for his services, _____________ percent (____%) of the amount recovered if settled without suit, or, ____________ (____%) of the amount recovered after suit is instituted by filing the first paper therein for litigation through Circuit, Chancery, or Federal Court. In the event of an appeal to the State Supreme Court or the Federal Appellate Courts, ATTORNEY shall be further entitled to all penalties assessed against the Defendant , as his fee. All costs and expenses advanced by the ATTORNEY shall be deducted from the CLIENT'S share. 2. CLIENT hereby assigns and gives ATTORNEY a lien on said claim, cause of action, and/or any sum recovered by way of settlement or judgment thereon for the sum and share hereinabove mentioned as his fee. CLIENT hereby agrees that said Attorney's lien shall attac h in full (in the percentages set out in paragraph one (1) to any offer of settlement extended in this matter while ATTORNEY is employed. 3. CLIENT agrees that if this employment agreement is terminated by CLIENT for any reasons after employment begins but prior to a settlement offer being extended, that ATTORNEY is entitled to be paid for his time expended to the date of termination at a liquidated rate of ________ dollars ($______) per hour, plus reimbursement of all advanced cost and expenses. CLIENT agrees to pay said fees, cost and expenses prior to his file being returned to him, unless retaining said file prejudices the rights of the CLIENT. 4. CLIENT hereby agrees that if he elects to employ other counsel that said counsel shall be paid out of CLIENT'S share. ATTORNEY agrees to pay any counsel associated by ATTORNEY out of ATTORNEY'S share. 5. CLIENT hereby gives ATTORNEY his POWER OF ATTORNEY to execute all complaints, claims, contracts, checks, settlements, drafts, compromises, releases, verifications, 2 dismissals, deposits and orders as he would himself. CLIENT agrees that he will make no settlement except in the presence of his ATTORNEY or with his knowledge and approval, and should he do so in violation of this agreement, he agrees to pay ATTORNEY the sum and share indicated in paragraph one (1) of this agreement.6. The ATTORNEY hereby accepts employment in the above particulars and agrees to represent the CLIENT to the best of his ability and with all fidelity. 7. It is mutually understood that the masculine shall include the feminine and the neuter, and the singular shall include the plural, wherever used hereinabove. IN WITNESS WHEREOF, the parties have set their hands this the ________ day of __________________, 20_______. ATTORNEY: CLIENT(S): BY: ________________________ _______________________________ - 1 - MEDICAL AUTHORIZATION TO WHOM IT MAY CONCERN: I, the undersigned __________________________________________________, hereby authorize any physician, hospital, nurse, chiropractor, dentist, psychologist, or other medical attendant to furnish full and complete medical reports, records, and other information herewith requested by ______________________________________________, Attorney at Law, or to any representative, attorney or investigator from his firm. The purpose of this authorization is to allow the above attorney to obtain all medical records which will aid in or are necessary for the prosecution of claims I am making. This authorization includes the right to examine all x-rays and records of any kind, and the right to receive full and complete information pertaining thereto, including copies of all such records. This authorization is intended to and will allow the above attorney to obtain any and all medical records, and shall include any and all records prior to or subsequent to the date of the claim referred to above. In addition, it is expected that I may need further treatment beyond the date of this authorization, and you are therefore authorized and requested to provide to the above attorney any and all medical records related to examinations and treatment which take place subsequent to the date of the execution of this authorization, so long as this authorization has not been cancelled or revoked by me in writing. Your full cooperation with my attorney is requested. You are further requested to disclose no information nor discuss my medical condition with any insurance adjuster or other person without my written authority to do so. This authority shall be valid until cancelled or revoked by me in writing. A photostatic copy of this authorization shall be considered as effective and as valid as the original ALL PRIOR AUTHORIZATION IS HEREBY CANCELLED ______________ ______________________________ DATE PATIENT 1 FORM 4506 REQUEST FOR COPY OF TAX FORM OR INDIVIDUAL INCOME TAX ACCOUNT INFORMATION (OMB Clearance Number 1545-0429) 1. Name of taxpayer as shown on tax form Current name and address 2. If information is to be mailed to someone else, show the third party's name and address Name 3. Address If name in third party's records differs from item 1 above, show here (see instructions for item 4. 3) 5. Social security or employer identification number as shown on tax form Spouse's social security number as shown on tax form Spouse's name 6. Spouse's SS no 7. Tax form number (Form 1041, 941, etc.) 8. Tax period(s) (No more than 4 per request) Amount due (Make check payable to IRS) $ 9. Note: Full payment must accompany your request 10. Describe what you want (Check only one box) $5.00 each Copy of tax return and all attachments (including forms w-2) Note: if you need these copies certified for court or administrative proceedings, check here also $2.50 each Tax account information only (do not use for income averaging) $2.50 each Form 1040a or form 1040ez verification only PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE We ask for this information to carry out the Internal Revenue laws of the United States. We need the information to gain access to your return in our files and properly respond to your request. If you do not furnish the information, we may not be able to fill your request. DATE Signature Telephone 1 Out of Pocket Expenses Client DOCTOR BILLS $ $ $ $ $ $ $ TOTAL DOCTOR BILLS $ DRUGS $ $ $ $ $ TOTAL DRUG BILLS $ HOSPITAL $ $ $ $ $ TOTAL HOSPITAL BILLS $ 2 PROPERTY DAMAGE $ $ $ $ $ TOTAL PROPERTY LOSS $ EARNINGS LOSS $ $ $ $ $ TOTAL EARNINGS LOSS $ OTHER LOSS $ $ $ $ $ TOTAL OTHER LOSS $ TOTAL OUT OF POCKET LOSS $