Lawyer Client Intake Questionnaire for Medical Malpractice Claim

Download this free Referral Acknowledgement and Release form to be signed by a client who has been referred to a lawyer in a specific matter.

• The form releases the referring party with respect to any claims arising from the matter being referred.
• The client acknowledges that they are relying solely on the advice of the lawyer they have been referred to.
• This is a generic form which can be used in many jurisdictions.
• Available in MS Word format.

Lawyers can use this Intake Form to collect the information they need from a client to launch a personal injury case.

Scope of the Intake Questionnaire

The 24-page form contains numerous sections for information gathering, including:

• personal details about the client, spouse/partner and children,
• employment, education, community involvement,
• military service,
• hobbies and activities,
• the accident / incident that resulted in the injury,
• details about the injury, diagnosis, prognosis, treatment and ongoing effects,
• medical expenses, vehicle repair costs, and other related costs,
• insurance details for all vehicles involved,
• medical history,
• driving records,
• criminal history,
• a section for slip and fall injury claims.
• Available in MS Word format and fully editable to fit your exact needs.

Format and Use

The Client Intake Questionnaire is available in MS Word format and is downloadable, fully editable and reusable as a template. It can be used anywhere.