Get Westcare Dental New Client Intake - Personal Injury Form
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How to fill out the Westcare Dental New Client Intake - Personal Injury Form online
Completing the Westcare Dental New Client Intake - Personal Injury Form online is an essential step in ensuring effective representation for your case. This guide will walk you through each section of the form to help you provide accurate and comprehensive information.
Follow the steps to complete the form accurately and efficiently.
- Click ‘Get Form’ button to obtain the form and open it for completion.
- Enter today's date in the designated field at the top of the form.
- Fill in your personal information, including your name, age, birthdate, and Social Security Number.
- Provide your address, including street, city, state, and zip code.
- Input your contact details such as phone number, cell number, fax number, and email address.
- Indicate your marital status and, if applicable, provide your spouse's name, occupation, and monthly take-home pay.
- List the names and ages of your children, if applicable.
- Complete information about your employer, including the employer's address, job title, and your hourly wage.
- Record the number of days you missed work due to the accident.
- In the section titled 'What happened?!', provide a detailed account of the accident including names, dates, times, and circumstances.
- List any witnesses or anyone who can provide additional information regarding the accident.
- Detail the treatment you sought, including names and addresses of medical providers.
- Outline your injuries or physical complaints starting from the most severe.
- Answer questions regarding your ability to return to work, any restrictions, and previous ratings for permanent impairment.
- Disclose any relevant criminal record from the last five years, if applicable.
- Identify the person or organization you believe to be at fault for your accident and their insurance details.
- Mention any other insurance that may cover lost wages or medical bills.
- Describe any activities you can no longer perform due to the accident.
- Indicate whether a police report was filed or if any statements were provided to insurance companies.
- Include details of any prior accidents or injuries that may relate to this case.
- Provide any additional information, documentation, or details you feel are important for your case.
- Once completed, save your changes, then download, print, or share the form as needed.
Start filling out your Westcare Dental New Client Intake - Personal Injury Form online now.
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Clients should receive information on consent to treatment, a description of services offered, financial policies, privacy practices, and contact information for follow-up inquiries. By including these elements in the Westcare Dental New Client Intake - Personal Injury Form, we ensure clients feel informed and supported throughout their care journey. This proactive communication fosters a positive patient experience and builds long-term trust.
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