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Fighting For Boston Families For More Than A Decade
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Onboarding Test Form
Medical Malpractice Client Onboarding Form – Comp. by Client
First Name
*
Last Name
*
Date of Birth
*
Occupation
*
Home/Mailing Address (Line 1)
*
Home/Mailing Address (Line 2)
City
*
State
*
Zip Code
*
Please describe any conscious pain that you suffered as a result of the injuries caused by the defendant:
Generally, in your own words, how did this incident occur?
Who was your primary care physician at the time of the events?
Please describe your educational and professional history:
Please state any conversations and/or communications you are aware of with the defendants:
Are there any writings or notes or journal entries about the incident? If so, please explain:
Were you Medicare eligible at the time of the incident? Please answer "Yes" or "No":
*
What health insurance did you have at the time of the incident?
Did you suffer monetary losses, lost wages, or lost benefits as a result of this incident? Please explain:
Please upload any Medical Records relating to the incident above.
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Max. file size: 50 MB.
Please upload any Medical Records relating to the incident above.
Please upload your Autopsy Report above.
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Max. file size: 50 MB.
Please upload your Autopsy Report above.
Please upload any Medical Bills or Hospital Bills resulting from the incident above.
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Max. file size: 50 MB.
Please upload any Medical Bills or Hospital Bills resulting from the incident above.
Please upload any Photographs or Videos relating to the incident above.
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Max. file size: 50 MB.
Please upload any Photographs or Videos relating to the incident above.
Please upload any and all Investigative and/or Incident and/or Accident Reports above.
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Max. file size: 50 MB.
Please upload any and all Investigative and/or Incident and/or Accident Reports above.
Please upload copies of all Lien Letters and Notices relating to this litigation from CMS regarding Medicare/Medicaid liens above.
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Max. file size: 50 MB.
Please upload copies of all Lien Letters and Notices relating to this litigation from CMS regarding Medicare/Medicaid liens above.
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