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Free Confidential Case Evaluation
*All indicated fields must be completed
Type of Case: Medical Malpractice
  Personal Injury
  Product Liability
Identity of Individual Reporting Injury:
First Name:
Last Name:
I would like to be addressed as:
Street and Apt#:
Zip Code:
Day Phone:
Evening Phone:
Fax Number:
Information About Injured Person:
The following information is about myself: Yes No
If "No", my relationship to injured is:
Identity of the Injured Person:
Full Name:
Date of Birth:
Marital Status: Single Married
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:
Legal Information:
Have you contacted other lawyers about your potential case?* Yes No
If “Yes,” did any lawyer agree to represent you? Yes No
Are you still being represented by that lawyer? Yes No
Insurance Information:
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? Yes No
Do you have medical records, medical bills, or other related documents in your possession? Yes No
Other Information:
How did you hear about my practice?
How did you find my website?