This is a test page Warm Transfer Intake Script - Vocatum Multi-step Subscribe Vocatum Multi-Step Intake ScriptIntake Agent Name- Select -Carlos ZambranaGary SanchezGerson AnguloHillary RodriguezIsaac RiveraJay MappusJeffry VargasJhosson ChavezJimena ZúñigaJuan Carlos SalasKendall PotoyKimberly VargasKristin RodriguezMaria Gabriela FonsecaRangel MorganSteven RodriguezCallers IDExisting Lead/Project ID (will update existing lead)Organization- Select Organization -DeGaris LawMcDonald Worley, P.C.Shepherd Law GroupThompson StamUnsureCase Type- Select Case Type -AutoBair Hugger Heating BlanketBicycle AccidentClass ActionDog BiteMed MalMotorcycleNursing HomePedestrian AccidentPersonal InjuryPremisesSlip and FallWorkers Compensation CaseAuto - Sub Casetype - Select -18 Wheeler AccidentBus AccidentCommercial AccidentDefective TiresDefective VehicleDiminished ValueHead On CollisionHigh Limit Personal PolicyHigh Ploicy Limits Liability InsuranceIntersectionLeft TurnMinimum PolicyParking LotPersonal InjuryRear EndRed LightRight TurnRolloverSideswipeSnow and IceStop SignTo Be DeterminedTrain AccidentU TurnMotorcycle - Sub Casetype - Select -18 Wheeler AccidentBus AccidentCommercial AccidentDefective TiresDefective VehicleDiminished ValueHead On CollisionHigh Limit Personal PolicyHigh Ploicy Limits Liability InsuranceIntersectionLeft TurnMinimum PolicyParking LotPersonal InjuryRear EndRed LightRight TurnRolloverSideswipeSnow and IceStop SignTo Be DeterminedTrain AccidentU TurnPersonal Injury - Sub Casetype - Select -AssaultAstroworldAuto AccidentBirth DefectBlindnessBlood ClotBoeingBrain DamageBreast CancerBroken BonesBroken CurbBruisesBus AccidentCommercial AccidentCommercial PolicyContaminated BloodCross OverDeathDefective BrakesDefective DesignDefective GuardDefective PartDefective Railroad CrossingDefective SeatbeltDefective StairwayDefective StepsDefective TiresDefective WarningsDepressionFailure to RemoveFailure to Sand or SaltFailure to Timely DiagnoseFailure to Timely TreatFalling DebrisForeign BodyFraudGopherHigh PolicyImprisonmentImproper DesignImproper DiagnosisImproper RemovalImproper RepairLadderMesotheliomaMinimum Policy LimitsMissouri Train DerailmentMotor Vehicle PolicyNon-SubscriberParking LotPedestrian - Hit and RunPedestrian vs DriverPeloton TreadmillPersonal InjuryProbateProduct DefectRoadwayRolloverScaffoldSidewalkSlip and FallSnow and IceStairwayTo Be DeterminedUber/LyftUM Auto AccidentUnknownVehicle DefectVision LossWrongful DeathPremises - Sub Casetype - Select -Animal bite needing surgeryAnimal bite not seriousCeiling CollapseCommercial PolicyCribCross WalkDeathDefective StairwayDefective StepsHead TraumaImproper DesignImproper RepairLadderLoose HandrailParking LotSidewalkSlip and FallSnow and IceStairwaySub Type UnknownTo Be DeterminedLead Source- Select Lead Source -Triple DigitalHub NationalJarred - Sue the Collector (STC)xSocialLS5Top Class ActionTriten LawArcherFocus DMGLawsuit LegalLeadsForceDavis CrumpMorgan and MorganUnsureCaller's First NameCaller's Last NameCaller's Phone/MobileAre you calling for yourself or someone else?- Select -MyselfSomeone ElseIf Someone ElseFirst NameLast NameRelationship to Caller (Spouse, Parent, Guardian, Sibling, Care Taker, Granschild, Father, Mother, Child, Other - Explain)Is the person you are calling on behalf of a minor? Yes NoAre they deceased? Yes NoDate of DeathCause of DeathIn what capacity do you represent your loved one?- Select -Executor/administrator of estateTrusteeConservatorLegal GuardianAttorney-in-fact (power of attorney)ParentOther AgentDo you have legal authority to sign on their behalf? Yes NoCall SIDPreviousNextAuto, Motorcycle and Bicycle Accident1. Were you given a ticket for this accident? Yes No2. Was the accident more than 18 months ago? Yes No3. Do you already have an attorney? Yes NoThank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance. Restart Form4. In what state did this incident occur?- Select State -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming5. Did you seek medical attention within 48 hours? Yes NoPlease advise the caller to seek medical attention before scheduling a callback.Thank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance. Restart FormClass ActionCA1. Is this in regards to a defective product or dangerous drug case? Yes NoCA1-1. Please select it from the list below.- Select -Metal hip implantNexium or PrilosecEssureTransvaginal meshOtherCA1-2. Please enter what this is in regards to.CA2. Is there anything specific you’d like me to include in the message?Dog BiteDB2. Did you receive ANY medical attention the same day or WITHIN 48 hours of the accident (ie, ER or Urgent Care)? Yes NoDB1. On what date did this incident happen?DB3. Which of the following describes your injuries? Amputation Surgery Torn Ligament Bone Fracture or Break Serious Disfigurement Concussion Scarring SprainDB4. In what state did this incident occur?- Select -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingDB5. Do you know the owner of the dog? Yes NoMedical MalpracticeMM1. What was the date of the incident?If it is a non-birth injury and happened more than 2 years ago please send to the Texas Bar. A birth injury may be accepted if it occured within the past 20 years.MM2. Did this result in loss of life? Yes NoMM3. Please tell me about your situationMM4. Did the medical facility or doctor explain why this may have occurred? Yes NoMM5. In what State did this occur?- Select -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingMM6. In what City did this occur?MM7. What hospital were you admitted to?MM8. Who was your doctor?MM9. Date of BirthMM10. What is your Gender?MM11. What damages did you sustain?MM12. Did you receive any follow up treatment? MM13. Was the medical treatment a result of the negligence? Yes NoMM14. Did you receive a permanent physical injury as a result of the negligence? Yes NoMed mail cases that allege dissatisfaction or the care was not good are not cases and should be rejected outright. Nursing Home AbuseNH1. Did you or a loved one sustain an injury due to a nursing home’s negligence? Yes NoNH2.Was the date of the injury more than 6 months ago? Yes NoNH3. In what state did this injury occur?- Select -GeorgiaNew JerseyNew YorkNorth CarolinaOklahomaPennsylvaniaTexasOtherNH4. What type of injury did you or your loved one sustain? Bedsores Fall/Broken bones Death OtherPremisesPR1. What was the date of incident? (If more then 18 months disqualify)PR2. Did you seek medical attention within 48 hours of incident? Yes NoThank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance.Restart FormPR3. Where did the incident take place?PR4. Did you complete an incident report? Yes NoPR5. In what state did the incident occur? - Select -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingPedestrian AccidentPA1. Did you seek medical attention within 48 hours of the accident? Yes NoPA2. Did you sustain any injuries in this accident? Yes NoPA3. Did the police arrive on the scene and do a police report? Yes NoThank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance. Restart form PA4. Did anyone receive a ticket? Yes NoPA5. In what State did the accident occur?- Select -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingPersonal Injury1. Did you sustain any injuries in this accident? Yes No2. Can you briefly describe the accident?3. Were you taken by ambulance to the hospital? Yes No4. What state did the accident occur in?- Select -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingThank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance.Restart FormSlip & FallSF1. What date was the accident?SF2. Based on the date provided above was the accident greater than 18 months ago? Yes No UnknownSF3. Did you suffer an injury that required / requires medical treatment? Yes No UnknownSF4. Did you receive ANY medical attention the same day or WITHIN 48 hours of the accident (ie, ER or Urgent Care or your doctor) or will you seek treatment within 48 hours? Yes NoThank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance.Restart Form SF5. At what address/location did the fall take place?SF6. Please describe how you fell.SF7. Were there any warning or hazardous signs near the area? Yes No UnknownSF8. Which of the following best describes your injuries (multi-choice)?Death (only ask if the caller is calling on behalf of someone else)AmputationSurgeryTorn LigamentBone Fracture or BreakSerious disfigurementMRI or CT scan doneConcussionPhysical Therapy is recommendedScarringSprainWhiplashPainSF9. Were you transported to the hospital via ambulance after the accident? Yes NoSF10. Was an accident report completed? Yes No UnknownSF11. If you happen to know it, what is the name of the owner of the property where you fell?Workers' CompensationWC1. Please describe your legal issue.WC2. Did you sustain any injuries in this accident? Yes NoThank you (Mr./Ms. Last Name) for reaching out but after reviewing your information, unfortunately, we will not be able to assist at the time. However, you may contact your local Bar association for further assistance.Restart FormWC2-1. Were you taken to the hospital by ambulance from the scene? Yes NoWC2-2. Did you seek medical attention within 48 hours of the accident? Yes NoWC3. What type of treatment have you received?WC4. What were you diagnosed with?WC5. Are you still receiving treatment for your injuries?WC6. Please tell us how the accident happenedWC7. If a product (e.g. machine, scaffolding, etc.) was involved, do you believe the product was defective?WC8. Are you still working for this company? Yes NoWC9. What are your dates of injury? WC10. When did you return to work?WC11. Were you given any pre or post-employment exams, tests, or drug screen? WC12. Where did the injury occur?13. Did you report the injury to anyone?WC14. Have you already filed a workers’ compensation claim? Yes NoWC14-1. What was the outcome?PreviousNextIn case we are unable to reach you by phone, what is your email address?Can I also get a good mailing address for you?Country- Select -AndorraUnited Arab Emirates (the)AfghanistanAntigua and BarbudaAnguillaAlbaniaArmeniaAngolaAntarcticaArgentinaAmerican SamoaAustriaAustraliaArubaÅland IslandsAzerbaijanBosnia and HerzegovinaBarbadosBangladeshBelgiumBurkina FasoBulgariaBahrainBurundiBeninSaint BarthélemyBermudaBrunei DarussalamBolivia (Plurinational State of)Bonaire, Sint Eustatius and SabaBrazilBahamas (the)BhutanBouvet IslandBotswanaBelarusBelizeCanadaCocos (Keeling) Islands (the)Congo (the Democratic Republic of the)Central African Republic (the)Congo (the)SwitzerlandCôte d'IvoireCook Islands (the)ChileCameroonChinaColombiaCosta RicaCubaCabo VerdeCuraçaoChristmas IslandCyprusCzechiaGermanyDjiboutiDenmarkDominicaDominican Republic (the)AlgeriaEcuadorEstoniaEgyptWestern SaharaEritreaSpainEthiopiaFinlandFijiFalkland Islands (the) [Malvinas]Micronesia (Federated States of)Faroe Islands (the)FranceGabonUnited Kingdom of Great Britain and Northern Ireland (the)GrenadaGeorgiaFrench GuianaGuernseyGhanaGibraltarGreenlandGambia (the)GuineaGuadeloupeEquatorial GuineaGreeceSouth Georgia and the South Sandwich IslandsGuatemalaGuamGuinea-BissauGuyanaHong KongHeard Island and McDonald IslandsHondurasCroatiaHaitiHungaryIndonesiaIrelandIsraelIsle of ManIndiaBritish Indian Ocean Territory (the)IraqIran (Islamic Republic of)IcelandItalyJerseyJamaicaJordanJapanKenyaKyrgyzstanCambodiaKiribatiComoros (the)Saint Kitts and NevisKorea (the Democratic People's Republic of)Korea (the Republic of)KuwaitCayman Islands (the)KazakhstanLao People's Democratic Republic (the)LebanonSaint LuciaLiechtensteinSri LankaLiberiaLesothoLithuaniaLuxembourgLatviaLibyaMoroccoMonacoMoldova (the Republic of)MontenegroSaint Martin (French part)MadagascarMarshall Islands (the)Republic of North MacedoniaMaliMyanmarMongoliaMacaoNorthern Mariana Islands (the)MartiniqueMauritaniaMontserratMaltaMauritiusMaldivesMalawiMexicoMalaysiaMozambiqueNamibiaNew CaledoniaNiger (the)Norfolk IslandNigeriaNicaraguaNetherlands (the)NorwayNepalNauruNiueNew ZealandOmanPanamaPeruFrench PolynesiaPapua New GuineaPhilippines (the)PakistanPolandSaint Pierre and MiquelonPitcairnPuerto RicoPalestine, State ofPortugalPalauParaguayQatarRéunionRomaniaSerbiaRussian Federation (the)RwandaSaudi ArabiaSolomon IslandsSeychellesSudan (the)SwedenSingaporeSaint Helena, Ascension and Tristan da CunhaSloveniaSvalbard and Jan MayenSlovakiaSierra LeoneSan MarinoSenegalSomaliaSurinameSouth SudanSao Tome and PrincipeEl SalvadorSint Maarten (Dutch part)Syrian Arab RepublicEswatiniTurks and Caicos Islands (the)ChadFrench Southern Territories (the)TogoThailandTajikistanTokelauTimor-LesteTurkmenistanTunisiaTongaTurkeyTrinidad and TobagoTuvaluTaiwan (Province of China)Tanzania, United Republic ofUkraineUgandaUnited States Minor Outlying Islands (the)United States of AmericaUruguayUzbekistanHoly See (the)Saint Vincent and the GrenadinesVenezuela (Bolivarian Republic of)Virgin Islands (British)Virgin Islands (U.S.)Viet NamVanuatuWallis and FutunaSamoaYemenMayotteSouth AfricaZambiaZimbabweAddress Line 1Address Line 2CityState - 2 Letter ID- Select -AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingZipCountyWould you like to add an emergency contact? Yes NoEmergency Contact InfoEmergency Contact First NameEmergency Contact Last NameEmergency Contact Relationship to youEmergency Contact Phone NumberHow did you hear about us?- Select -Attorney ReferralFamilyFriendsBusinessOnlineRadioTVAnd what station/program was that on?Thank you for reaching out to our firm. We are going to pass this information along to our attorney to review and we will get back to you shortly.Lead SummaryLead SummaryLead Status- Select -Send Email of Lead to FirmSend Retainer ContractSend Printed Retainer ContractRetainer Sent By TextAdminNew LeadRejectedDisqualifiedVerified Quality LeadIntake NotesTriple Intake Status- Select -Declined Retainer ContractDisqualifiedDuplicate LeadEmailed to FirmLCC PursuingLost - AmenitiesLost - AvailabilityLost - OtherLost - PriceOtherPossible Refer OutRejectedRejection Email SentRetainedRetainer SentReviewing FIrm's PreferenceSet AppointmentSet Appointment on CalendlyTriple PursuingUnable to ReachUnder ReviewVerifiedLanguage- Select -EnglishSpanishCreolePortugueseOther - See Intake Notes Previous Submit Form
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