Registration

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Client Information








YESNO

YESNO

Defendant Information


Accident Information


YESNO

Employment Information


YESNO

What is your Rate of pay

Days missed from work






Present Complaints

HEADACHESVERTIGODIZZYNAUSEA
MEMORYVOMITINGFACEJAW
NOSETEETHMOUTHEYES
EAR PAIN/RINGINGNECKCHESTUPPER BACK
MID BACKLOW BACK
SHOOTING PAIN FROM NECK INTO SHOULDERS/ARMS
SHOOTING PAIN FROM LOW BACK INTO HIPS/BUTTOCKS/LEGS

Medical Treatment


AmbulanceHospitalX-RaysScansUrgent CarePrimary Care

Health Insurance Information


HMOPPO



Passenger Information

WAGE LOSS

Days missed from work



What is your rate of pay?

Verification

SOCIAL MEDIA ACCOUNTS:

Please provide your account names (not your passwords) for the following social media accounts. Insurance companies may look up your public profile on these accounts, so it is important that we see what the insurance company will see:

VERIFICATION OF DATE OF ACCIDENT (must be written/typed in by client):

I,hereby certify that the above Date of Accident is true and correct and I understand that MANIBOG LAW, PC is relying on the accuracy of the Date of Accident I have provided herein to calculate the applicable statute of limitations regarding my claim. I understand that I assume the risk of the Date of Accident being inaccurate including the risk that the statute of limitation may not be protected due to MANIBOG LAW, PC relying on an inaccurate Date of Accident. I understand if the statute of limitations is not protected, I would forever los the right to recover damages related to my accident.


VERIFICATION OF ACCURACY OF INFORMATION PROVIDED:

I,hereby certify that all the information I have provided on this Intake Form is true and accurate to the best of my knowledge. I understand that MANIBOG LAW is relying on the truthfulness and accuracy of the information provided herein in handling my claim. I am further aware that any inaccurate or untruthful information may harm my case. I agree to update/change this form and notify MANIBOG LAW of any updates/changes if I discover that any of the information I have provided herein is or becomes inaccurate.