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CONFIDENTIAL INJURY INTAKE FORM Medical Malpractice AttorneyClient Interview Anthony J. Persia & Associates, Ltd. 5130 S. Archer, Chicago, IL 60632 INJURY INTAKE FORM It is important that you complete
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How to fill out a confidential injury intake form:

01
Begin by carefully reading the instructions provided on the form. This will give you a clear understanding of what information needs to be provided.
02
Fill in your personal details, such as your full name, address, phone number, and email address. This information is necessary for contacting you regarding your injury.
03
Provide a detailed description of the incident or injury. Include the date, time, and location of the incident, as well as any relevant circumstances or witnesses.
04
If applicable, indicate whether you have sought medical treatment for your injury. Provide the name of the healthcare provider, the type of treatment received, and any medications prescribed.
05
Describe the extent of your injuries and the impact they have had on your daily life and activities. Include details such as pain levels, limitations in mobility, or emotional distress.
06
If you have already communicated with any insurance companies or legal representatives regarding your injury, provide their contact information and any reference numbers or claim details.
07
Review your form for completeness and accuracy before submitting it. Make sure all sections have been filled out and that your handwriting is legible.

Who needs a confidential injury intake form:

01
Individuals who have experienced an injury due to an accident or incident.
02
People seeking legal representation or assistance in pursuing a personal injury claim.
03
Insurance companies or legal firms requesting comprehensive information about the injury for evaluation or settlement purposes.
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Confidential injury intake form is a document used to gather information about workplace injuries in a confidential manner.
Employees who have experienced a workplace injury are required to file the confidential injury intake form.
The form should be completed with detailed information about the injury, including date, time, location, and description of the incident.
The purpose of the form is to record and document workplace injuries for reporting and investigation purposes.
Information such as date, time, location, description of the injury, and any witness statements must be reported on the form.
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