CLIENT INTAKE FORM First Name: Last Name: Phone: Email: Zip: Date of Birth: Date of Injury: Case Number: Body Parts Accepted: Body Parts Denied: EMS Transport: --None-- Yes No Hospital: --None-- Yes No Report Needed: --None-- Medical Cost Projection Life Care Plan Medical Record Review Medicare Set-Aside Rush?: --None-- Yes No Law Firm: Attorney: Primary Contact Name at Law Firm: Primary Email at Law Firm: Primary Phone Number at Law Firm: Comments
