Injury intake form

A. Cohen Law Firm Clients

Date

Full Legal Name

Address

Cell

Date Of Birth

SSN

Medicare/Medicaid?

Prior Accidents? Please provide dates

Date Of Injury

Location Of Injury

Direction Of Travel

Description Of Accident

Plaintiff’s Vehicle

Plaintiff’s Insurance Carrier

Damage To Vehicle

Defendant’s Plate No./Make/Model

Defendant’s Insurance Carrier

Witnesses Names and Phone Numbers

Ambulance?

Hospital?

Describe the Nature of Injury

Right/Left-Handed

List All Medical Providers related to Accident and Dates Treated

Names and Ages of all Immediate Family Members

Will you Require Future Medical Care?

Medical Expenses Incurred To Date

Occupation & Company Name

Lost-Time from Work? Dates?

Describe any Limitations Affecting Daily Life

Attach Any Files You May Have