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PLEASE BE CERTAIN THAT THERE IS A FULL UNDERSTANDING THAT NOTHING CONTAINED HEREIN IS TO BE CONSTRUED TO BE IN ANY MANNER AN AGREEMENT OR A CONTRACT TO PROVIDE LEGAL SERVICES. FURTHER, THE SUBMISSION OF INFORMATION IN NO WAY ESTABLISHES AN ATTORNEY-CLIENT RELATIONSHIP NOR DOES IT ESTABLISH AN OBLIGATION TO PROVIDE ANY ADVICE OR LEGAL INFORMATION. WE ATTEMPT TO COMMUNICATE BACK TO ALL CORRESPONDENCE BUT DEPENDING UPON OUR DEPOSITION, TRAVEL, TRIAL PREPARATION AND TRIAL SCHEDULE AND THE ACTIVITY OF RESPONSES, WE MAY NOT BE ABLE TO DO SO IN A TIMELY FASHION. WE DO NOT REPRESENT ANYONE UNLESS THE CONTRACT FOR LEGAL SERVICES HAS BEEN SIGNED. NOTE: REQUIRED INFORMATION HAS AN * NEXT TO THE FIELD.

GIVEN THE PRECEDING PREAMBLE, FEEL FREE TO SUBMIT ANY OF THE FOLLOWING INFORMATION:


* Name		  
Home Phone

Date of Birth		  
Work Phone

Address 1		  
* Email

Address 2		  
Education Level

City, State, ZIP		  
Employment

INSTITUTION AND/OR PHYSICIAN AGAINST WHOM YOU THINK YOU MAY HAVE A CLAIM? PLEASE INCLUDE ALL THE INFORMATION BELOW



Physician		  
Institution

Address		  
City, State, ZIP

Date of Injury		  
Approximate Medical Bills

Approximate Time Out of Work		    

What Is The Medical Problem From Which You Are
Suffering Now?

Have You Had Any Other Attorneys Look Into This
Matter For You?

Give A Very Brief Description Of What Occurred Or To Ask Questions
(100 Words or Less)

BY SUBMITTING THIS INFORMATION, I UNDERSTAND THERE IS NOT AN ATTORNEY-CLIENT RELATIONSHIP, UNLESS A CONTRACT FOR LEGAL SERVICES HAS BEEN SIGNED.

YOU MAY ALSO CONTACT US BY PHONE: TOLL FREE: 800-458-1133


   

 

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