Request Forms

Below you'll find six forms to help Dr. BiFulco and his staff help you.

New Case Intake

Please tell me about you, your loved one, or your medical/legal case. 

Once I receive this, I will be happy to speak with you by phone or in person.

Comprehensive Patient History Form

Thank You for taking your valuable time to complete this form. It is a Secure form, and the information you fill out WILL HELP ME TO HELP YOU. Please set aside ABOUT 30 to 60 MINUTES of uninterrupted time to complete.

Returning Visit Form

The more information I have about your current condition, the more help I can be to you.

Current Balance Request

Find your current balance for your Law Firm, Medical Practice, or Company.

Record Request Form

Help us with your request for records. Please fill out 1 form per client.

Preliminary Life Care Plan Questionnaire

Intake Form

Deposition Request Form

Patient Questionnaire

Not Sure Which Form to Fill Out?

We'll walk you through it.

Learn More

Meet Dr. BiFulco

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