Personal Injury - Firm Consultation

Client Name:

First Last

Defendant's Name:

Date of Injury:

SOL Estimate:

Referral Source:

Fee Arrangement:

Have you had any injuries that required medical attention before this injury:

Please answer the following:

Date of Injury:

Description of Injury:

Provider/Facility:

City/State:

Do you have any ongoing medical conditions?

(Diabetes, high blood pressure, seizures, etc.)

Please answer the following:

Condition:

Date of Diagnosis:

Provider/Facility:

City/State:

Other medical providers seen in the 10 years before this injury:

Provider Name/Facility:

City/State:

Were you wearing a seatbelt?

Amount of property damage:

Paid?

By:

Was law enforcement present?

Was someone ticketed?

Who:

What:

Personal Injury – Firm Consultation