Case Intake Form

tFill out the Case Intake Form Below

NOTE: After you complete the case intake form, we'll send an estimated time & cost range for approval.

Firm Name *

Case Name *

List the Attorney and all firm team members that will be involved in this case *

Email *

Phone *

Case Type *

Personal Injury

Medical Malpractice

Wrongful Death

Mass Tort

Class Action

Product Liability

Criminal Defense

Date of Injury/Loss (If known)

Scope of Work (Select all that apply) *

Chronology

Chronology & Report

Demand Letter - Standard

Demand Letter - Expanded

Merit Review

IME / DME / DPE

Case Summary Report

Brief Summary

Deposition Preparation

Expert Location

Other - place in additional deliverable Instructions

List the following information for the IME / DME / DPE below: Date of exam, location of exam, copy of the DME notice, any objections, client contact information, audio and or video instruction

Litigation Status *

Pre-Litigation

Litigation

Total Page Count (If known)

How would you like to send us the medical records? *

Send Loveless LNC your medical record link

Upload to Loveless LNC Dropbox

File request link to be put in your hub in Basecamp

Other as coordinated with Loveless LNC

Medical record upload link

Is this an expedited case? (Less than 7-10 business days) *

Yes

Case Synopsis *

Additional deliverable instructions (If applicable)

By checking this box, I consent to receive non-marketing text messages from [BUSINESS NAME] about [USE_CASE_FROM_CAMPAIGN_DESCRIPTION]. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from [BUSINESS NAME] at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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