Intake Form - The Smith Law Firm

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THE SMITH LAW FIRM, PLCC - NEC Litigation Intake Form

This secure information form helps us get to know more about you, your infant's injury, and how The Smith Law Firm may be able to help you with your potential case. You may save this form in case you are interrupted by clicking the "Save" button to allow you to pick up where you left off.

Injured Party Information (Infant):

Please provide this info for the infant who was diagnosed with NEC.

Infant Name(Required)

First Middle Last Suffix

Infant Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

SSN(Required)

A Social Security Number is required by medical providers to ensure they release the correct, official medical records.

Gestational age of infant at birth (# of weeks)(Required)

Date of Death (if applicable)

Weight of Infant at Birth(Required)

State located at death (if applicable):

If your infant is deceased, please list the state in which your infant passed away

Gender(Required)

Male

Female

Race(Required)

Personal Representative Information (Mother):

Mother's Legal Name(Required)

Prefix First Middle Last

Mother's Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone(Required)

Marital Status(Required)

Mother's Date of Birth(Required)

SSN(Required)

Social Security Numbers are required by medical providers to release official medical records.

Email(Required)

Is The Smith Law Firm representing this parent?(Required)

Yes

Personal Representative Information (Father):

Father's Legal Name(Required)

Prefix First Middle Last Suffix

Father's Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone(Required)

Marital Status(Required)

Father's Date of Birth(Required)

Father's SSN(Required)

Social Security Numbers are required by medical providers to release official medical records.

Email(Required)

Is The Smith Law Firm representing this parent?(Required)

Yes

Secondary Contact Persons

We recommend that you add secondary contacts to help us get in touch if we lose contact with you and need to hear from you, or to continue your case if you become incapacitated.

Would you like to add a secondary contact?(Required)

Secondary Contact Legal Name(Required)

Prefix First Middle Last Suffix

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Email(Required)

Relationship to Personal Representative(s):(Required)

Do we have permission to speak with this secondary contact about your representation by our firm?(Required)

Yes

Do you have another secondary contact you would like to add?(Required)

Additional Secondary Contact Legal Name (if applicable)

Prefix First Middle Last Suffix

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Relationship to Representative(s):

Do we have permission to speak with this secondary contact re your representation by our firm?

Yes

Infant Diagnosis & Treatment Details

Was your infant diagnosed with NEC?(Required)

Yes

Name of facility where your infant was born:(Required)

Address of facility where infant was born?(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of facility where diagnosed with NEC, if different:

Address of facility where diagnosed with NEC, if different

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

NEC Intake Form

THE SMITH LAW FIRM, PLCC - NEC Litigation Intake Form

Injured Party Information (Infant):

Personal Representative Information (Mother):

Personal Representative Information (Father):

Secondary Contact Persons

Infant Product Use

Infant Diagnosis & Treatment Details