Personal Injury Intake Form
Tell us briefly what happened and how you were injured. Our office will review your information and contact you regarding the next step. Submitting this form does not create an attorney-client relationship. Please do not send confidential documents unless requested by our office.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did the incident occur?
*
Briefly describe what happened
*
Please include how the incident occurred and who you believe may have been responsible.
What type of incident occurred?
*
Please Select
Dog Bite or Animal Attack
Car Accident
Pedestrian Accident
Bicycle Accident
Slip and Fall
Trip and Fall
Other Premises Injury
Other Personal Injury
What injuries did you suffer?
*
Cuts or Lacerations
Scarring or Disfigurement
Broken Bone
Head Injury or Concussion
Neck or Back Injury
Shoulder, Arm, Hand, Leg, or Knee Injury
Soft-Tissue Injury
Emotional or Psychological Effects
Other
Did you receive medical treatment?
*
Yes
No
Where did you receive treatment?
*
Ambulance
Emergency Room
Urgent Care
Primary Care Physician
Specialist
Physical Therapy or Chiropractic Care
Surgery
Other
I have not received treatment
Was the incident reported?
*
Police Report
Animal Control Report
Property or Business Incident Report
Insurance Company
Employer
No Report Was Made
Other
Do you have photographs, video, or other evidence?
*
Yes
No
Not Sure
Were there any witnesses?
*
Yes
No
Not Sure
Do you know whether the person, business, property owner, or animal owner has insurance?
*
Yes
No
Not Sure
Have you missed work or lost income because of your injuries?
*
Yes
No
Not Applicable
Has an insurance company contacted you about this incident?
*
Yes
No
Insurance company name
Have you already received or signed any settlement, release, or payment related to this incident?
*
Yes
No
Are you currently represented by another attorney for this matter?
*
Yes
No
Has another attorney previously reviewed or declined this case?
*
Yes
No
If yes, please briefly explain.
Are you still receiving treatment?
*
Yes
No
Treatment has been recommended but has not started
SUBMIT INTAKE
Should be Empty: