Intake form 2026

1. Click ‘Get Form’ to open the intake form in the editor.
2. Begin by entering the date and your Social Security Number (SSN) at the top of the form. This information is crucial for identification purposes.
3. Fill out your personal information, including your name, address, birth date, age, sex, and contact numbers. Ensure all details are accurate to avoid any delays.
4. In the accident information section, provide details about the incident such as the date, location, and any police report information. Be thorough in explaining how the accident occurred.
5. List any injuries sustained during the accident and indicate if you have been released from treatment. Include details about treating doctors and any surgeries discussed.
6. Complete the insurance information section by providing details about both your insurance and that of the other driver involved in the accident.
7. Finally, indicate how you were referred to our office. This helps us understand how clients find us.

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