Comprehensive intake form for personal injury cases
Legal template · 19 fields (12 required) · ~4 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
Comprehensive intake form for personal injury cases.
This template ships with 19 fields, ready to use as-is or as a starting point. Open it in the editor to add, remove, or reorder fields, match it to your brand, then share a link or embed it on your site — no code needed.
Every field, explained
Client Name (Name, required)
Email Address (Email, required)
Phone Number (Phone, required)
Home Address (Address, required)
Date of Injury/Incident (Date, required)
Describe the Incident (Long text, required)
Location of Incident (Short text, required)
Type of Accident (Dropdown, required)
Injuries Sustained (Long text, required)
Did you seek medical attention? (Single choice, required)
Hospital/Medical Facility (Short text)
Current Medical Treatment (Long text)
Are you still receiving treatment? (Single choice, required)
Was a police report filed? (Single choice, required)
Police Report Number (Short text)
Witness Information (Long text)
Insurance Company (Short text)
Insurance Policy Number (Short text)
Additional Information (Long text)
Frequently asked questions
Is the Personal Injury Intake Form template free?
Yes. The free plan includes 5 active forms and 100 responses a month, with no credit card required. Responses over the limit are held — never lost — and unlock when you upgrade.
Can I customize the fields?
Yes — every field is editable. Add, remove, reorder, or restyle fields in the drag-and-drop editor, add conditional logic, and match the form to your brand.
How do I share the finished form?
Publish it to get a share link, embed it on your website, or generate a QR code. Responses arrive in your dashboard with email notifications, CSV export, webhooks, and Zapier.