CRPS Case Claims

1

What type of CRPS do you have?* This field is required.

CRPS Type-1CRPS Type-2

3

Were you admitted to a hospital?

YESNO

4

Did you have surgery or any therapy?

YESNO

5

Do you currently have a pain specialist?

YESNO

6

Are you based in Victoria? Or did the incident occur in Victoria?

YESNO

7

May we have your name, please* This field is required.

First Name

Last Name

8

Congratulations {Name:first}, you may have a claim for CRPS

Based on the information you have provided us, it is very likley that you have a potential claim for your CRPS injuries. In the next few steps, we will ask you to leave your contact details with us so that a personal injury law specialist can get in contact you to confirm your potential claim.

9

Email Address* This field is required.

example@example.com

10

Mobile Number* This field is required.

11

Your Location* This field is required.

Suburb

Postcode

Country

12

Would you like to add any details about your CRPS before you submit?

YESNO

13

Tell us a bit more about your {Type} condition.

14

Source

15

Medium

16

Campaign

17

Term

18

Content

19

URL

20

Keyword

21

Sender

22

User Agent String