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Fill out this form to request a free review by a personal injury lawyer or attorney.
have you or a loved one been injured?
[please select]
Yes
No
type of personal injury accident:
[Please Select]
Car, Auto or Motor Vehicle Accident
Truck or Tractor Trailer Accident
Motorcycle Accident
Bike or Bicycle Accident
Airplane, Train, or Bus Accident
Medical Malpractice
Doctor & Hospital Negligence
Drug Injuries & Drug Side Effects
Medical Device Injuries & Side Effects
Defective or Recalled Product Injury
Exposure To Toxic Substances
Slip, Trip or Fall
Work Injury or Job Related Accident
Other Personal Injury Accident
employer's name:
injured person's job title:
injured person's job description:
what toxic substance, chemical or toxin was the injured person exposed to:
describe the toxic exposure:
i.e., how were you or a loved one exposed to the toxic chemicals or toxins?
name of doctor or healthcare provider who committed medical malpractice:
name of hospital or medical facility where medical malpractice occurred:
describe the medical malpractice or negligence:
(i.e. what happened? how were you injured by a doctor, hospital or other healthcare provider?)
date of medical malpractice or negligence:
MM slash DD slash YYYY
name of defective product:
name of product manufacturer:
describe the product defect and/or your product defect complaint:
(i.e., how is the product defective, unsafe or dangerous?)
was the product recalled:
[select]
Yes
No
Don't know
name of drug taken or prescribed:
(i.e., which prescription drug, medicine, medication, Rx or pharmaceutical caused injuries?)
name of drug manufacturer:
when did you start taking the drug:
MM slash DD slash YYYY
when did you stop taking the drug:
MM slash DD slash YYYY
what dosage of the drug was taken:
name of defective medical device or product:
name of medical device manufacturer:
describe the medical device defect and/or your medical device complaint:
(i.e., how is the medical device or product defective, unsafe or dangerous?
was the medical device or product recalled?
[select]
yes
no
i don't know
describe the personal injury accident, incident or complaint:
date of personal injury accident:
MM slash DD slash YYYY
name of person, entity or company who caused the accident or injuries:
state where injury or accident occurred:
[Please Select]
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
name of company, person or entity that owns or controls the property upon which injured person slipped, tripped and/or fell:
type of injury or injuries suffered:
broken bones & fractures
spinal cord or vertebrae damage
burns & burn injury
internal organ damage
severed limbs or loss of body parts
disfigurement, scars & wounds
lacerations, cuts & punctures
sprains, strains or tears
scrapes, scratches & bruises
bleeding & blood loss
soft tissue injuries
joint dislocated & dislocation
birth injuries & birth defects
paralysis, quadriplegia or paraplegia
loss of motor function
traumatic brain injury TBI
concussion
coma or unconscious
wrongful death
other personal injuries
describe any injury or injuries suffered:
type of propery on which slip, trip and fall occurred:
Residential property (i.e., house, apartment, etc.)
Commericial or Business property (i.e., hotel, restaurant, etc.)
Government
Other type of property
describe the injuries, side effects, illnesses, diseases or symptoms suffered after taking the drug:
(i.e., what is your drug injury complaint? how were you hurt or injured?)
are the injuries, side effects, illnesses or symptoms permanent?
[Please Select]
Yes
No
Don't know
what part of body was injured:
head injury & head trauma
brain injury & brain damage
neck injury
shoulder injury
back injury
chest injury
stomach, naval or abdomin injury
arm and elbow injury
hand, wrist, finger or thumb injury
hip injury
leg injury or knee injury
eye, nose, mouth, ear or face injury
foot, ankle or toe injury
internal organ injury
other parts of body injured:
medical treatment received or required by injured person:
hospital or emergency room ER visit
treated by physician or doctor
prescribed drugs or medication
surgery or surgical procedure
stiches, staples or bandages
crutches and/or wheelchair
casts and/or braces
prosthetic
amputation
physical therapy PT
occupational therapy OT
ambulence or medical transport
chiropractic treatment
rehabilitation or rehab
x-ray, CT or CAT scan or MRI
other medical treatment
describe any medical treatment required or received by injured patient or party:
(i.e., how did doctor, physician or hospital treat injuries?)
damages & losses suffered:
medical bills & expenses
lost wages, income or earnings
missed work
pain and suffering
loss of consortium
loss of enjoyment of life
loss of a loved one
property damage
other personal injury damages
describe any damage or loss suffered:
estimated medical bills & expenses:
estimated lost wages or income:
estimated property damage:
other expenses or damages:
gender of injured person:
[Please Select]
Male
Female
age of injured person:
your first name:
*
your last name:
*
name of injured person, if different, and relationship to you:
address:
*
city:
*
state:
*
[Please Select]
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
zip / postal code:
*
daytime phone number:
*
evening phone number:
*
email:
*
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