Client Intake - Richards Willis PC

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Date of Birth(Required)

Make sure to enter the full year for your date of birth.

Social Security Number

Best Method to Reach You

Best Times to Reach You

Marriage Status

Married

Single

Divorced

Number of Children

If married, spouses name

On What Date Did Your Injury Occur?

Approx. time of injury

Where Did Your Injury Occur?

City State ZIP Code

Location/Address of where accident occurred- (i.e. street names, nearest intersection and/or cross street).

How Did Your Injury Occur?

Were you transported by an ambulance?

Yes

Name of Ambulance Company, if known

Was a police/accident report taken?

Yes

If yes, please provide copy and/or the report number, if known:

Max. file size: 50 MB.

Report number if known

Do you have health/medical insurance?

Yes

(Please provide a copy of the front and back of your medical insurance card)

Max. file size: 50 MB.

Do you have Medi-Cal or Medicare?

Yes

(Please provide a copy of the front and back of your medical insurance card)

Max. file size: 50 MB.

Do you have car insurance?

Yes

If so, please provide Name of car insurance and Policy #

Do you have Med-Pay/PIP medical coverage as part of your car insurance policy?

Yes

(Please provide a copy of your car insurance Declaration page)

Max. file size: 50 MB.

If applicable, your car insurance’s UM/UIM Coverage (uninsured/underinsured motorist)

Describe how your injury occurred

Describe your injury(ies).

List all doctors and other health care providers who have treated your injuries, including their names, addresses, and telephone numbers. (Please provide a copy of ALL medical provider’s visit summary and/or discharge papers)

File

Max. file size: 50 MB.

Are you still seeking medical treatments and/or therapy? If so, list all doctors and other health care providers you are currently treating with regarding your injuries, including their names, addresses, and telephone numbers.

Have you lost income as a result of your injuries?

Yes

(please provide a copy of 4 payroll stubs prior to the accident)

File 1

Max. file size: 50 MB.

File 2

Max. file size: 50 MB.

File 3

Max. file size: 50 MB.

File 4

Max. file size: 50 MB.

Income before injury

Income after injury

Employer

Position

Employer’s address

Street Address Address Line 2 City State ZIP Code

Are you currently working?

Yes

Expect to return to work?

Yes

Will Not Return to Work

Describe any other ways in which your life has changed as a result of your injuries. (For example, you are no longer able to engage in athletic activities, your appearance has changed, you cannot care for your children, etc.)

If married, has your spouse experienced any losses as a result of your injury? If so, describe.

List the names, addresses, and phone numbers of any possible witnesses in your case.