Free Confidential Case Evaluation
*All indicated fields must be completed
Type of Case:
Identity of Individual Reporting Injury:
I would like to be addressed as:
Street and Apt#:
Information About Injured Person:
The following information is about myself:
If "No", my relationship to injured is:
Identity of the Injured Person:
Date of Birth:
Month, day, year the injury occurred:
City and state where the injury occurred:
Please give a brief description of the injury, describing the nature of the injury and how you believe it came about:
Please describe any disability, lost wages, medical expenses and other damages resulting from the injury:
Have you contacted other lawyers about your potential case?*
If “Yes,” did any lawyer agree to represent you?
Are you still being represented by that lawyer?
Have you been contacted by the lawyer or insurance company for the person / doctor / hospital / other healthcare provider believed to be responsible for the injury?
Do you have medical records, medical bills, or other related documents in your possession?
How did you hear about my practice?
How did you find my website?