| * Your
name |
|
| * Preferred e-mail
address |
|
| * Please confirm e-mail address |
|
| * Your phone
number |
|
| * Your address |
|
| Name of Injured
(or deceased) person |
|
| Your relationship
to the injured person (if not you) |
|
| If individual is deceased, date of death |
|
| Cause of death on the death certificate |
|
| |
|
Questionnaire |
|
| |
|
| 1.
* How were you (or your loved one) injured? |
|
| Describe
here if you answered "other" |
|
| 2.
* When were you injured (date or approximate date) |
|
Month |
|
* Year |
|
| |
|
| 3.
* Description of injuries (check all that apply) |
|
Brain/Head |
|
Back
or Neck |
|
Broken
Bone(s) |
|
Internal
Organ(s) |
|
Nervous
System |
|
Muscle
of Soft Tissue |
|
Loss
of Limb (or) other Body Part(s) |
|
Reproductive
System |
|
Heart/Circulatory
System |
|
Burn |
|
Pain |
|
Allergic
Reaction |
|
| Other,
describe |
|
| |
|
| 4.* Who
treated your injuries (check all that apply) |
|
Ambulance/EMT |
|
Hospital |
|
Urgent
Care |
|
Primary
Care Physician |
|
Specialist(s) |
Specify
|
Homeopathic
Physician |
|
Chiropractor |
|
Physical
Therapist |
|
Other |
Describe
|
| |
|
| 5.
* Estimate of medical charges to date |
|
| 6.
* Are you still injured or experiencing symptoms |
Yes
No
Not Sure
|
7.
Who was at fault? (if known) |
|
| How were they at fault if known?
|
|
| Additional
comments |
|
| |
|
| In order to insure that your questionnaire is received by lawyers in your local community, please select the city closest to you. |
* City |
|
| |
|
| |
Submit Form
|
| |
|
| Reset Form
|
|
