ONTARIO'S PERSONAL INJURY LAW FIRM

AGENT INTAKES

General Intake Form

General Intake Form New (Agent)

INTAKE: Good Morning/Afternoon. Thank you for calling the Oatley Vigmond intake team. My name is XXXXX, and I’m here to help. May I have your name and email, please?

Caller Name

Caller Phone

Caller Email:

Are you calling on behalf of yourself or a loved one?

Myself

Loved One

INTAKE: Thank you. I want to start off by expressing how sorry I am that you (or your loved one) were involved in this accident. I understand that making this call is very challenging in the circumstances.

I am going to ask you some questions about the incident so that our lawyers can help determine the best course of action. I’m going to ask you some questions about the accident first and then about the injuries you or a loved one sustained, and then finally some questions about the injured person. I know that some of these questions might be difficult to answer, so please take as much time as you need.

I’m here to help you through the process. Are you ok with this plan?

The injured person’s name and relationship to the caller:

The best phone number to reach the caller in case of disconnection:

Can you please tell me your/their Date of birth by Month day Year, thank you

INTAKE: I am now going to ask you some questions about the accident. I know these questions might be hard, but they are important. At the same time, it is ok if you don’t know the answers to all of the questions.

1. What type of accident was it, a car accident of fall or other? If car accident, were they the driver, passenger or a pedestrian?

2. What was the date of the accident? (Month day year)

3. Do you know where the incident took place, such as the intersection or address

4. If you remember, can you tell me about how the accident happened?

5. Did you/they lose consciousness, and if so, for how long?

6. Do you know if police attended the scene, if so local police or OPP? Do you have a copy of the incident report or tear sheet?

7. Do you know if anyone was charged as a result of the collision? If so, who?

8. Is there any other information about the accident/incident that you wish to share at this time?

INTAKE: I am now going to ask you some questions about the injuries you sustained in the accident. Again, it is ok if you don’t know the answers to all of the questions, just do your best.

1. Did you/they seek medical attention on the day of the accident? If not, do you remember when you first received medical attention?

2. If they attended a hospital, which one, and how long did you/they stay?

3. What injuries did you/they sustain/suffer as a result of the accident? Did you/they have surgery as a result of those injuries? Were x-rays taken or CT or other imaging?

4. Did you/they experience headaches/nausea/vomiting/ dizziness/sensitivity to light and noise after the accident?

5. Has any doctor diagnosed a concussion or traumatic brain injury?

6. Are you/they receiving any treatment for your injuries at the present time? Please list such as chiro, physio or massage

7. Have the injuries prevented you/them from working? Are they currently off work, if so, for how long?

8. Do your/their injuries interfere with day-to-day life?

INTAKE: Thank you for sharing this information. I only have a few more questions left.

1. Were you/they employed before/at the time of the accident?

2. What did you/they do for a living? Were you/they employed full time or part time?

3. Were you/they performing duties related to work/on the job or working when the accident occurred?

INTAKE: In order to ensure that you are connected to the right lawyer, can you tell me how you found out about our firm?

Did they refer you to a specific lawyer?

INTAKE: Thank you for sharing this information with me. The next step is for our lawyers to review this information in detail and determine the best course of action.

When would be a convenient time for a consultation, and what is the best way to contact you?

INTAKE: Thank you xxxx. Someone from the Oatley Vigmond team will get back to you to confirm the next steps once the lawyers have had an opportunity to review your case. Again, thank you for calling Oatley Vigmond.

Medical Malpractice Intake Form

Medical Malpractice Intake Form New (Agent)

INTAKE: Good Morning/Afternoon, thank you for calling Oatley Vigmond. My name is xxxx, and I’m here to help. May I have your name and email please?

Caller Name:

Caller Phone

Caller Email:

INTAKE: Thank you. I want to start off by expressing how sorry I am that this happened to you or your loved one. We are supposed to be able to trust our medical professionals to treat us correctly and with respect. I understand that making this call is very difficult in the circumstances.

I am going to take you through some questions about the incident so that our lawyers can help determine the best course of action. I’m going to ask you about yourself (or loved one), first, then ask some questions about that accident and finally about the injuries you sustained. I know that some of these questions might be difficult to answer, so please take as much time as you need. I’m here to help you through the process. Is that ok?

How old is the injured person? Please provide their Date of Birth (Month Day Year).

Was the injured person employed before the incident ?

What did the injured person do for a living? Full time or part time or self employed?

INTAKE: I am now going to ask you some questions about the medical treatment you received. I know these questions might be hard, but they are important. At the same time, it is ok if you don’t know the answers to all of the questions.

1. Can you please tell me about the illness and symptoms and when this started.

2. Can you tell me about the treatments received and health care providers involved in treatment, such as the facility/hospital, doctors or any other health care professionals.

3. Can you tell me about the mistake the health care provider made? Can you identify the individual and where and when.

4. What was the impact of the mistake?

5. When did the mistake happen? If possible, could you please tell me any significant dates of surgery or procedures.

6. When did you become aware of the mistake?

7. Is there any other information/concerns about the incident that you wish to share at this time?

INTAKE: I am now going to ask you some questions about the injuries you sustained as a result of the care you received. Again, it is ok if you don’t know the answers to all of the questions, just do your best.

Questions about the injuries

1. What injuries did you/they sustain as a result of the care you received?

2. Are you/they receiving any treatment for the injuries at the present time?

3. Have the injuries prevented you/they from working? If “No”, have they returned to work full time or in what capacity?

4. Aside from work, do the injuries interfere with your/their day-to-day life?

Firm and Lawyer Questions

1. In order to ensure that you are connected to the right lawyer, can you tell me how you found out about our firm?

2. Did they refer you to a specific lawyer?

All Other Intakes Form

All Other Intake Form New (Agent)

INTAKE: Good Morning/Afternoon. Thank you for calling the Oatley Vigmond intake team.

My name is XXXX, and I’m here to help. Could you please provide your name and phone number?

NAME:

PHONE:

INTAKE: Thank you.

Can I ask why you are looking to speak to a lawyer and how you would like us to help? (please collect any details they wish to share about the situation)

DETAILS:

Please advise the date of the accident or incident and the location. (Month/Day/Year)

Please advise the nature of the injuries sustained.

INTAKE: Thank you xxxx. Someone from the Oatley Vigmond team will get back to you to confirm the next steps once the lawyers have had an opportunity to review this information.

Again, thank you for calling Oatley Vigmond.

Is this case MVA related (optional)?

Yes