| Full Name: |
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| Email Address: |
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| Home Phone: |
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| Cell Phone: |
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| Work Phone: |
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| Street Address: |
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| City: |
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| State/Zip: |
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What is the best way to reach you?
Please provide the best place, time and method for contacting you. |
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| If you are NOT inquiring on your own behalf, what is your relationship?: |
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| Is the person deceased? |
Yes
No |
| If deceased, the cause of death as stated on the death certificate: |
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| Date of Death: |
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| Please give us a general idea when (month/year) the accident, surgery, treatment or exposure occurred: |
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| Please describe any medical procedures that took place: |
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| Do you believe there was a doctor error: |
Yes
No |
| What injuries were sustained as a result? |
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| Tell us in your words all the facts that you believe are important for us to understand about the incident. |
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| Is an attorney currently representing you for this matter? |
Yes
No |
| Other Information: |
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I understand that by submitting this form I am not retaining a lawyer.
Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal "retainer agreement." |
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