by Valley Mountain Medical, LLC
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We are currently working on making the Intake form even better.
This intake will give your attorney a snap shot of your case. Upon submission, you and your attorney will be sent a copy of the information you provide, so please make sure it's accurate.
If you have any questions, please contact your attorney.
Please provide the insurance information necessary to file a claim, such as Auto Accident Insurance or Worker's Comp.
If you don't know your policy limits, please leave this section blank.
Auto/Worker's Compensation insurance information can be provided below.
Provide all current treatment providers and how you contact them. This includes your primary care physician, physical therapists, psychiatrists, psychologists, other specialists, etc.
Provide as much detail as possible when describing your accident.
Fill out the following details regarding your work and/or school life at the time of the accident.
Please uncheck "Neither" to input work and/or school information.
Provide your work information at the time of the accident.
This section will allow you to report on the current status of your individual symptoms and where you find yourself in the recovery from your injuries. Even if your symptoms are mild and infrequent, they can indicate that you still require healing. For certain injuries, this may also indicate that you may not fully recover from them. It's important to be as accurate as possible.
This short questionnaire determines if you possibly have a brain injury or concussion.
Many people that are in accidents usually have more than 1 injury. When you have a major injury it’s very easy to overlook the many smaller injuries you might have received. If you don’t document those injuries you can easily forget them later, but they are a valuable source to your doctors and to your attorney in proving the severity of your injuries.
The following is a list of potential injury symptoms you may be experiencing after your incident.
When explaining your injury symptoms to us, please make sure you include the area they're being experienced. Such as, "Left Arm Numbness".
If you're experiencing fatigue or another injury symptom that does not require a location, please type "N/A", or not applicable.
The first symptom is required. If you're not currently experiencing any symptoms, please contact your attorney before proceeding.
This is your last chance to review your answers before submitting them to your attorney. To do so, click "Review Previous Sections" below.
If you've finished your review, interact with recaptcha before submitting.
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