Intake Survey

Texas Regional Physicians

    Attorney Contact Details

    Client Information

    Client Email

    Client Phone Number

    Client Date of Birth

    Client's Language*

    Claim Information

    Date of Loss

    Statue of Limitations

    Accident Information

    Please add other accident information below.

    Additional Accident Details

    Is there a Liability Dispute?

    Amount of Property Damage

    Total Special Damages to Date

    Please Upload Police or Incident Report, or Any Available Medical Records

    File limit 2MB.

    Insurance Company Information

    Liability Policy Confirmed in Force

    UM/UIM Policy Confirmed in Force

    MedPay/PIP Policy in Force

    When do you anticipate this claim to settle

    Has your client previously been represented by another law firm on this claim

    Prior Funding Details

    Has your client already received cash assistance, liens, or loans against this claim?

    Funding Request Details

    Is your client seeking medical assistance?

    Medical Funding Request

    Please select the treatment your client is seeking funding for

    Additional information regarding the injury

    Has there been a gap in treatment (> 30 days)

    Are you or your client aware of any pre-existing conditions?

    Does your client have health insurance?

    Additional Information

    Please provide any additional information you feel would be helpful to evaluating this request

    Would you like to receive an email notification?*

    HIPPA Compliant