Date of your accident:
Type of injury:
Auto
Dangerous Premises
Medical Malpractice
Dangerous Products
Other (Specify)
How did your accident happen?
Who was at fault?
If auto injury what was the dollar value of the damage
to your car?
What are your main bodily injuries?
Did you go to the emergency room
yes
no
Were you treated by a doctor after your accident?
yes
no
Who is your main doctor for this injury:
How much in medical expenses have you had so far?
$
How much time have missed from work?
hours, days, weeks
Were there any other passengers in your car?
yes
no
How were you referred to us?
TV
Yellow Page
White Pages
Friend
Lawyer or Doctor
Other
Saw Victor Makris speak in a seminar
If a person referred you to us please state their
name:
