Medical Professional Referral

At the law office of W. Shane Jennings, we specialize in Personal Injury cases, helping patients with everything from auto accidents to Personal injuries, while also assisting with reducing medical debt related to these cases. Referring your patients to us can benefit both their recovery and your practice. When patients face legal issues related to personal injuries, ensuring they receive expert legal support can help them access the compensation they need to cover medical expenses, allowing you to focus on their care and provide uninterrupted on going treatments. This collaborative approach not only strengthens patient trust and satisfaction but also reduces the administrative burden on your office by streamlining communication between medical and legal teams.

By referring your patients to us, you ensure they receive expert legal representation aimed at maximizing their compensation and easing their financial burden. Simply fill out the form below, and we’ll promptly provide the legal support your patients need. Together, we can ensure the best outcome for their full recovery and peace of mind.

Please enable JavaScript in your browser to complete this form.

Today's Date *

MM/DD/YY

Name Patient for

Referring Hospital/Clinic/Chiropractic *

Physician First Name

Physician Last Name

Phone *

Physician Email *

Email

Confirm Email

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Patient Information

Patient *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Date of Birth *

DD/MM/YY

Phone *

Patient Email *

Email

Confirm Email

Insurance Info

Injury Details

Date of Injury *

MM/DD/YY

Reason for Referral to Attorney *LOPCase won't settledDifficult AdjusterInsurance disputeslegal implicationslow ball offerMore bills than policy limitFred LoyaSerious Injury3rd Party Comp CaseOthers

Type of Injury *Animal AttackAuto AccidentAssault and BatteryPolice BrutalityFirearm AccidentPersonal InjurySlip and FallWork Place InjuryOthers

Locaton/County

Detailed of Injury

Referring Doctor Comments

Submit