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Consultation Information Form
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* Indicates required question
Email
*
Your email
First and last name
*
Your answer
Phone number
*
Your answer
Address
Your answer
Date of birth
MM
/
DD
/
YYYY
Employer at time of injury
*
Your answer
Address of Employer
Your answer
Date of injury
*
Your answer
Please describe the accident.
*
Your answer
What are your current work limits from the doctor due to this injury?
Your answer
Please list all medical providers for this injury.
Your answer
Have you been in touch with workers' compensation? If so, please give us their name(s) and contact information.
Your answer
Is workers' comp paying for medical treatment and/or paying you for time out of work?
Your answer
Job title at time of injury
Your answer
Please describe your job duties at time of injury.
Your answer
What was the name of your supervisor at the time of the injury?
Your answer
Please list witnesses to the injury.
Your answer
How long have you worked for this Employer?
Your answer
What was your gross pay per week at the time you were injured?
Your answer
After the injury, have you applied for unemployment, Social Security Disability, or Short- or Long-Term Disability? If so, which one and what is status of benefit?
Your answer
Please give your job history for the five years prior to working for this Employer.
Your answer
Please list pre-existing injuries prior to this on-the-job injury.
Your answer
Please list any chronic medical conditions that you have.
Your answer
Thank you for taking the time to complete this questionnaire! Someone with our office will be in touch with you soon. Feel free to visit our website at
www.forinjuredworker.com
for more information or reach out to our office at 404-660-2332.
A copy of your responses will be emailed to the address you provided.
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