PI Intake Form - Cohen Law Group

About You

Your Name(Required)

First Last

Your Phone(Required)

Date of Birth

Preferred Method of Contact

Best Time to Call You(Required)

Your Email Address(Required)

Where did you hear of us? (referral source)(Required)

Personal Injury Case Type(Required)

Have you been involved in an MVA in the past 5 years?

Location of Incident

Date of accident

Time of Incident

Brief description of accident

Location of Incident

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this the same address where the dog lives?

Dog's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does the owner of the dog rent or own their property?

Were the police called?

Was animal control called?

Type of Facility

Doctor’s Name (if you have it):

Location/Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Brief description of Medical Negligence/Malpractice

Injuries

Incident Report Filed?

Received any Follow-Up Care:

Follow-Up Care - where?

Employer Name

Job Title

Specific accident/repetitive injury/occupational illness

Have you sought medical treatment?

Medical Facility

Date

Diagnosis (if given):

Brief description of accident

Was there a police report filed?

Were your names at-fault?

Were there passengers in your car?

Any witnesses?

Did you go to the hospital?

Where did you go to hospital?

Were you transported via ambulance?

If not, have you received any medical care? (Urgent/Clinic/PCP):

Your Auto Insurance Carrier

At-Fault Driver's Auto Insurance Carroer

Health Insurance Carrier:

Any previous attorneys?

Have you signed any releases?

Did you receive any money?

Your Address

Street Address Address Line 2 City ZIP Code

Your Comments/Questions(Required)

CLG Intake Assistant / Case Manager