* Workers’ Compensation Client Intake Form:

Please make sure to fill out this form completely. We need to know all
the details of the injury, especially the date of injury. Please provide us
with ALL the names of the providers you have treated with in relation to this injury.

* Authorization for Release of Health Care Record:

Only sign this form. Please do not date or fill in any other information.

* Authorization for Release of Employment Records:

Only sign this form. Please do not date or fill in any other information.

* Authorization for Disclosure of Health Information

This form will be mail to client. Please just sign the form and do not date or fill in any other information.

* Retainer Contract

Please sign and date this form. For worker’s compensation we receive 20% of whatever benefits
we obtain for you. There is no fee unless we obtain the funds for you.

* Personal Injury Client Intake Form

Please make sure to fill out this form completely. We need to know all the details of the accident/injury, especially the date of injury. Please provide us with ALL the names of the providers you have treated with in relation to this injury.

* Authorization for Release of Health Care Records

This form will be mail to client. Please just sign the form and do not date or fill in any other information.

* Authorization for Disclosure of Health Information

This form will be mail to client. Please just sign the form and do not date or fill in any other information.

* Retainer Contract

Please sign and date this form. For personal injury cases we receive 1/3 of what we obtain for you. There is no fee unless we obtain the funds for you.