CASE QUESTIONNAIRE

Please Fill out This Case Questionnaire for Possible Consideration of Your Case

First Name *

Last Name *

Phone *

Email *

Type of Case * (select one)

Date of Accident or Occurrence*

Summary of Facts * (please provide a summary of facts)

Other Important Information * (anything else we should know?)

IMPORTANT LEGAL DISCLAIMER

If you would like me to consider your personal injury or wrongful death claim, please provide me with some information. I would like to know what happened to you (or your family member), when it happened and who you think was responsible. If the case involves injuries, please describe the medical care and how the injury has affected you. Tell me about the things in your life that have been impacted, such as your job and things you like to do.. If a family member died because of someone elses neglect, please describe their relationship to you. I personally review every submission and you will be contacted by someone from my office to let you know if I may be able to help you. However, until a written agreement is signed by both attorney and client, I am not responsible for your case (including any legal deadlines).

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