New Client Contact Information

Name _______________________________________________________________________________

Street Address _______________________________________________________________________

City _________________________________________ Province ______  Postal Code _____________

Phone (home) __________________ (mobile) ___________________ (office) ____________________

Email _______________________________________________________________________________

Date of Accident ____________________________

Type of Accident (check one)    [ ]Motor Vehicle Accident    [ ]Slip and Fall    [ ]Other

Injuries ______________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Date of Birth _____________________________ Health Card Number ___________________________

Employer_____________________________________________________________________________

Length of Employment _________________________________________________________________

Driver’s Licence Number ___________________

Social Insurance Number ___________________

Name of Doctor or GP ______________________________________ Dr.’s Phone ___________________

Doctor’s Address _________________________________________________________________________

Name of Physiotherapist _________________________________ Physio’s Phone  ____________________

Physiotherapist’s Address _________________________________________________________________

Who referred you to Fishman Lawyers?______________________________________________

1781 – 808 Nelson Street, Vancouver, BC, V6Z 2H2

(604) 682-0717, jan@fishmanlawyers.ca