Client Name
First Name
Last Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
MM
DD
YYYY
Please list all injuries you suffered as a result of this incident:
Don't be shy. Tell us everything that hurt or you were diagnosed with by a medical professional. If you don't know the name of it, just tell us the body part that was injured. Please also send photos of your injuries to email@seldenco.com (this is also VERY IMPORTANT as it can mean thousands—or tens of thousands—of dollars to your case).
Did you take the ambulance after this incident?
*
Did you go to the hospital after this incident?
*
If yes, what hospital and where was it?
Did you go to your primary care provider after this incident?
*
Who is your primary care provider? If you do not have one, leave blank.
Did you go to a medical specialist after this incident?
*
Like a orthopedic doctor, neurologist, etc.
If yes, please list all the medical specialists you saw for your injuries after this incident.
Did you see a physical therapist or a chiropractor for your injuries from this collision?
*
If yes, please list all the physical therapists or chiropractors you saw.
Please list the names of all other medical providers you saw for injuries related to this collision:
*
This is very important. If you don't tell us, we can't request their medical and billing records and can't claim them as part of your case. This could reduce the amount of your settlement.
Have you ever hurt the same areas of your body before this incident?
*
Same or similar injuries won't hurt your case, but we need to know about them in order to explain them.
If yes, please explain:
Have you ever been in any other similar incidents (including any other car accidents)?
*
If so, please tell us when, where, and what happened?
Have you ever made a claim for injuries before?
*
This includes previous auto, slip and fall, workers compensation claims, other personal injury claims or lawsuits, etc.
If yes, please explain:
Has your health insurance company told you it wants information about this case?
*
This won't hurt your case, but it's very important we know about it in order to protect your rights.
Do you have any government-sponsored health insurance?
*
(Medicaid/Medicare/TriCare/Champus/ChampVA, etc.) Again, this won't hurt your case, but it's very important we know about it so we can protect your rights.
If yes, please explain:
Did you miss any time from work as a result of this incident?
Please detail any daily activities you had difficulty doing or were not able to do due to the injuries you sustained in this incident:
Don't hold back, this is your opportunity to tell us how this incident and your injuries affected your day-to-day life.
Please describe how this incident and your related injuries affected your family and personal relationships:
Please describe how this incident and your related injuries affected your career and work relationships:
Please describe how this incident and your related injuries affected your hobbies and other recreational activities:
Please detail anything else you'd like us to know about how this incident and your injuries affected your life:
