Step 1 of 7 INTAKE FORM

Personal Injury Intake — Pre-Flight™

Complete this form to begin your Pre-Flight case analysis. All information is confidential and attorney-client privileged.

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Client
2
Incident
3
Injuries
4
Medical
5
Records
6
Impact
7
Review
1
Client Information
Basic identifying information for case records and medical records requests.
Required for medical records requests. This information is confidential.
2
Incident Details
A complete and accurate account of the incident, event, or occurrence that caused your injury or harm.
If no report was filed, note why.
Be as specific as possible. Include speeds, positions, and what other parties said or did.
2b
Other Party Information
Information about the person or entity you hold responsible for your injuries.
2c
Witnesses
Names and contact information for anyone who saw the incident or its aftermath.
3
Injury Details
Identify all areas of your body affected. Be thorough — injuries that seem minor can become significant.
Head — concussion symptoms, dizziness
Neck / Cervical spine
Right shoulder — immediate pain
Chest / Ribs
Left arm / Shoulder
Right arm / Hand / Fingers
Lower back / Lumbar spine
Hip / Pelvis
Left leg / Knee / Foot
Right leg / Knee / Foot

Click body regions to toggle. Red = selected/injured.

Prior injuries to the same area can affect causation analysis.
4
Medical Providers Seen
All doctors, clinics, hospitals, physical therapists, and other providers you've seen for these injuries — in chronological order.
Provider 1
Provider 2
Provider 3
Provider 4
5
Records & Documents Available
Select all documents you currently have. You can upload them below or bring them to your appointment.
5b
Upload Documents
Drag and drop files or click to upload. PDF, JPG, PNG accepted. Maximum 25MB per file.
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Drag files here or browse to upload
PDF, JPG, PNG, DOC — up to 25MB each
⚡ Signal Loom Pre-Flight Analysis

This analysis will be available immediately upon submission.

6
Impact & Damages
How has this injury affected your daily life, work, and finances? Be specific — this section directly supports your damages claim.
Gross (before taxes). Used to calculate lost wages.
7
Review & Sign
Review your information below, acknowledge the consent statements, and sign.
Karen Whitfield
DOB: March 3, 1978
Rear-End MVA — Sep 14, 2024
Maple Ave & 5th St, Seattle
Cervical disc herniation C5-C6
4 providers seen
Off work — 26 days
Lost wages: est. $15,166
I certify that the information provided in this form is true and accurate to the best of my knowledge, and that I have not omitted any material facts related to my injuries or the incident.
I authorize the release of my medical records to the law firm of Aaron Jones, JD and its agents for the purpose of evaluating and pursuing my personal injury claim. (HIPAA Authorization)
I understand that completion of this form does not create an attorney-client relationship, and that I should seek independent legal advice regarding my rights.
I consent to have my intake information and medical records processed through Signal Loom Pre-Flight™ for case analysis and organization purposes. (Pre-Flight Privacy Policy)
⚡ Pre-Flight™ — Automated Analysis Preview
Upon submission, Pre-Flight will automatically:
  • Extract and structure all medical records chronologically
  • Identify clinical events, diagnoses, and treatment decisions
  • Cross-reference against orthopedic and neurosurgical clinical guidelines
  • Flag potential deviation points and care gaps for attorney review
  • Assess causal relationship between incident and diagnosed injuries
  • Generate a case brief ready for attorney review and case evaluation
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Intake Submitted — Pre-Flight Analysis Starting

Your information has been received. Signal Loom is now processing your intake and medical records. Your Pre-Flight case brief will be ready shortly.

Pre-Flight Case Reference
PF-WA-2024-0914-001