Case Intake Form

Other Case Type Case Intake Form

Step1
Step 2
Step3
Step Final

Section1

The incident occurred on:

Describe the claim:

As a result of the incident, I sought medical or hospital care:

Yes No

Section4

The injuries have caused me to:

seek medical attention

experience discomfort and pain

lose time from work

lose time from school

reduce my activities

Other - Explain Below

Please Explain:

Additional Information:

My name:

My email address is:

My telephone number is:

I understand that the transmission of this information does not create an attorney client relationship but is, instead, a request for a free consultation with an attorney about the details of my potential case.

Disclaimer

l understand and agree.

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