July 30, 2010
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White Finger Intake Form

Please fill out the information requested below and a representative will contact you.

Name:


Address (City, State, Zip)


Email


Home Phone


Work Phone


Name and Address of Most Recent Employer


Job Title


Date Hire


Date Retire


Do your hands go white?
Yes
No

Do your hands, wrists or forearms ache?
Yes
No

Have you got problems with your hands in the cold?
Yes
No

Do you have problems with your hands due to using vibrating power tools?
Yes
No

Do your hands tingle and go numb?
Yes
No

What makes your hands tingle and go numb?


Have you been diagnosed by a doctor with any hand problems?
Yes
No

If yes, list name and address of doctor and date of diagnosis.


Are you covered by health insurance?
Yes
No

Do you or have you used the following tools?
Fein Knife or Cut-Out Tool
Percussive tools e.g. riveting, caulking, fettling and swaging
Grinders including pedestal and hand-held grinders
Pneumatic drills and hammers, including percussive and rotary hammers
Chain saws and other garden machinery

Other Tools


Have you ever worked in the windshield replacement industry?
Yes
No

Date of workers' compensation or disability claim filed for hands

First Name: Last Name:
Phone:
-

Sending this message does not create an attorney-client relationship, which can be done only after personal consultation and with a written retainer agreement.
Office Locations
Jersey City

660 Newark Avenue
Jersey City, NJ 07306
Phone: (201) 656-8500
Toll: 1-(866)-333-3529
info@bagoliefriedman.com
Clifton Offices

790 Bloomfield Avenue
Clifton, NJ 07012
Phone: (973) 546-5414

157 Ackerman Avenue
Clifton, NJ 07011
Phone: (973) 546-5414
Florida Office

3900 Hollywood Blvd.
Hollywood, FL 33021
Phone: (954) 966-2322
Fax: (954) 927-0337
© 2010 - Bagolie Friedman, LLC
Personal Injury Attorneys serving clients in the State of New Jersey. All Rights Reserved.

Disclaimer: The New Jersey personal injury, wrongful death, worker's compensation, medical malpractice, nursing home abuse, product liability, environmental litigation, social security law, railroad / FELA, firefighter hearing loss, Asbestos / Mesothelioma, Lead Paint Poisoning and/or other legal information offered herein by Bagolie Friedman, LLC - Jersey City and Clifton New Jersey and Hollywood Florida Personal Injury Attorneys is not formal legal advice nor the formation of an attorney client relationship. Our law firm is licensed to practice law in New Jersey, New York and Florida. Nationwide and international coverage through associated counsel.