SLIP & FALL INTAKE Please answer as many of the questions as you can. The more information we have the better.Answer the questions that apply. Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Accident MM DD YYYY Time of Accident Hour Minute Second AM PM Spouse's Name First Name Last Name Spouse Phone Number (###) ### #### Your Driver's License Number Where did the accident happen? If possible, please provide city and street names: What time did the accident happen? Where were you going to, and from where? Please explain what happened: (Be as detailed and specific as possible) Is there a police report/incident report? If so, what is the report number? Do you have health insurance? If so, who is your carrier and policy number? Are you a Medi-Cal or Medi-Care recipient? If so, please provide your Medi-cal or Medi-Care number: Did you go to the hospital? If so, please provide the name and address of the hospital: Name and phone number of all medical providers Name and phone numbers of everyone that was involved in the accident (including passengers and pedestrians): Name and phone numbers of all known witnesses Describe your injuries: Have you been prescribed or have been taking medication? Please state what medication: Future Medical Appointments Provide Name, address, phone, and for what purpose? Any previous similar injuries? Explain: Are there any pictures of the accident or injuries? Anything else that you would like us to know? Thank you! You’ll hear from us shortly!
