Intake Form

Patient Demographics
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleOtherDecline
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Type of Phone

HomeOfficeCell
Email*
example@example.com
Appointment Information
Speciality

Pain Management (Spine Care)Orthopaedics (Extremities)
Case Type*
Date of Accident*

MonthDayYear
Date
Appointment Type

IMEEvaluation/Treatment
ATP

YesNo
Georgia Claim?

YesNo
PPD Rating (IME only)

YesNo
Payment Type

Health InsuranceFundingLien
Payment Type

Health InsuranceFunding
Preferred Funding Company
Health Insurance Company & Member ID Number
Body Part(s) To Be Evaluated*
Attorney Information
Attorney Name*

First NameLast Name
Attorney Phone Number*

Area CodePhone Number
Attorney Fax*

Area CodePhone Number
Attorney Email*
example@example.com
Assistant/Paralegal

First NameLast Name
Insurance Information

**Please provide ONLY 1st Party Payer Information. We do NOT file 3rd Party**
Insurance Carrier
Claim Number
Adjuster Name

First NameLast Name
Adjuster Phone Number

Area CodePhone Number
Adjuster Fax Number

Area CodePhone Number
Adjuster Email
example@example.com
Claims Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload any/all Medical Records pertinent to the case

Browse Files

Cancelof
Should be Empty:

Patient Demographics