Client details

Start with who was hurt. Each injured person gets their own HIPAA form, and a parent or guardian signs for anyone under 18.

Who was hurt in the accident?

An adult An adult and their minor child(ren) Only a minor child (or children)

Client

Full legal name

Street address

City

State

ZIP

Mobile phone

Email

Date of birth

Social Security numberMedical providers use it to match your records. It appears only on the HIPAA authorization.

The accident

A short account is enough. An attorney will go over the details with you.

Date of the accident

How did it happen?0 / 1200

Was a police report made?

Yes No Not sure

Was the accident your fault?

No Yes Partly / not sure

Did you get medical attention?

Yes No

Have you had pain or headaches since the accident?

Yes No

Review the documents

Read both documents before signing. Highlighted text comes from your answers.

Engagement agreement HIPAA authorization

Your answers

Sign the engagement agreement

Your signature goes on the Attorney Engagement Agreement with today's date and time.

I have read the Attorney Engagement Agreement, including the 33 1/3% / 40% contingency fee, and I agree to its terms. I agree to sign electronically, and my drawn signature has the same effect as my handwritten signature.

Sign with your finger

×

Sign here

Sign the HIPAA authorization

This lets your doctors and hospitals send your records and bills to the firm. Sign again below.

I authorize release of my medical records and billing to The Buckhead Law Firm (Saxton Firm, P.C.) as described in the HIPAA authorization.

Signature of patient

×

Sign here

Signed

Emailing documents…

Sending the signed engagement agreement and HIPAA authorization to intake@saxtonfirm.com.

The saved PDF has both signed documents, the intake answers, and a signature record. Nothing is kept on this device once you start a new client.