Fill and Sign the Wage Loss Form

- 1 - 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 DISCOMFORT NAME 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 appropri ate information below. - 2 - DATE COMPLAINT Rx TAKEN HOSPITAL EXPENSES NAME 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. ADMIT/DISCHARGE HOSPITAL NAME AND ADDRESS DOCTORS NAME AND ADDRESS FROM TO AMOUNT $ $ $ $ - 3 - $ $ $ $ $ $ $ $ $ $ $ DOCTOR’S EXPENSES 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. DATE MODE OF TRANSPORT DOCTOR'S NAME AND ADDRESS TYPE OF TREATMENT TOTAL BILL $ $ $ $ $ $ $ $ $ - 4 - $ $ $ $ $ $ - 5 - PHYSIOTHERAPY NAME 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. DATE MODE OF TRANSPORT DOCTOR'SNAME AND ADDRESS TYPE OF TREATMENT TOTAL BILL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PRESCRIPTION COSTS NAME OF CLIENT Enter all prescription and non-prescription drugs, bandages, etc. - 6 - DATE PHARMACY DOCTOR DRUG Rx # DOSAGE BILL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ MISCELLANEOUS EXPENSES NAME OF CLIENT Keep all sales receipts for everything that pertains to your case. Enter expenses for a mbulance, nurses, domestic help, personal property loss, etc. DATE EXPLAIN AMOUNT $ $ $ $ $ - 7 - $ $ $ $ $ $ $ $ $ $