call now
(617) 391-9001
Home
About
About Our Law Firm
Attorneys
Boston Personal Injury Blog
Boston Personal Injury Resources
Client Reviews
Community Involvement
Personal Injury FAQ
Video Center
We’re Hiring
Personal Injury
Construction Accidents
Mass Torts
Medical Malpractice
Product Liability
Slip & Fall Accidents
Wrongful Death
View All +
Vehicle Accidents
Car Accidents
Motorcycle Accidents
Truck Accidents
Areas We Serve
Case Results
Contact
Find Us
call now
617-391-9001
call now
617-391-9001
Fighting For Boston Families For More Than A Decade
scroll down
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.
Drop files here or
Select files
Max. file size: 50 MB.
Please upload any Medical Records relating to the incident above.
Please upload your Autopsy Report above.
Drop files here or
Select files
Max. file size: 50 MB.
Please upload your Autopsy Report above.
Please upload any Medical Bills or Hospital Bills resulting from the incident above.
Drop files here or
Select files
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.
Drop files here or
Select files
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.
Drop files here or
Select files
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.
Drop files here or
Select files
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.
Comments
This field is for validation purposes and should be left unchanged.
Δ
