INJURED? For information on how we can help you, Contact our office today: 504-588-1500
toll free:1-800-960-1526

email us

  
Home Firm Overview Attorney Profiles .Personal Injury Overview Intake Form Resource Links Contact us
 
2615 Pan American Life Center
601 Poydras Street
New Orleans, Louisiana 70130
 
Maritime Law
Catastrophic Injury and Wrongful Death
Medical Malpractice
Drug and Medical Device Injuries
Products Liability
Hospital Errors / Nursing Negligence
Nursing Home Injuries
 


 

INTAKE FORM
_____________________________________________________________

Personal Injury Intake Form

Name:
Address:
City:
State:
Zip:
Email Address:
Home Phone:
Business Phone:

Cell 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?
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?

The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk.

From our law offices in New Orleans, Louisiana, our personal injury lawyers serve clients along the Gulf Coast, from Texas to Alabama. We can help clients in Florida, Mississippi, and anywhere in the US in matters of maritime law and serious personal injury.

Contact us today to schedule your free initial consultation.
toll free: 1-800-960-1526 local: 504-588-1500

  

Home Firm Overview Attorney Profiles .Personal Injury Overview Intake Form Resource Links Contact us