Personal Injury Intake Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
Yes  No 

If "Other," was this a road accident?
Yes  No 

If no, did the injury occur on another's property?
Yes  No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes  No 

If yes, what are their names/contact information?

Were others involved or injured at the same time?
Yes  No 

If yes, what are their names/contact information?

Was there a police report?
Yes  No 

Did the injured person receive medical treatment?
Yes  No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes  No 

Was the injured person killed as a result of the accident?
Yes  No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

 

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A California and Texas attorney serving Silicon Valley, the South Bay, and the Central Coast area with criminal and civil litigation services. If you have been hurt, or have a San Jose or Santa Cruz legal problem, custody dispute, criminal defense matter, or any other legal problem, contact us today. We serve San Jose, Santa Cruz, Oakland, San Francisco, Salinas, Monterey, Los Gatos, Capitola, Soquel, Sunnyvale, Mountain View, Campbell, Palo Alto, Watsonville, Fremont, Pebble Beach, Scotts Valley, Marina, Morgan Hill, ,Saratoga, Santa Clara, Cupertino, Gilroy, and Hollister. Santa Cruz County - Santa Clara County - San Benito County - Monterey County and more, including the East Bay and Monterrey Bay. In Texas we serve Harris County, Dallas County, Bexar County and Travis County and focus our efforts in the Houston area, the greater Dallas area, and Austin/San Antonio. Also licensed to practice in Texas and Federal Courts around the United States.