Client Intake Form

All responses are confidential and will be reviewed by Paul Mann.

If this is an urgent matter that requires immediate assistance, please call the office directly at (519) 623-0700.

Full name:

Date of Birth:

Address:

City:

Home Phone:

Business Phone:

Cell Phone:

Email Address:

When did the event (injury) occur?

Where did the event (injury) occur?

Please describe the event and the resulting injuries:

How has this impacted your daily life and/or employment?

Please identify the health care professional(s) who you think acted inappropriately:

How did you hear about Paul Mann Professional Corporation?

Paul MannProfessional Corporation