Catastrophic Injuries Contact Form

Name

Email Address

Phone Number

How were you injured?

Who do you believe caused your injuries?

What are your injuries?

What body functioning has been impaired?

What activities are you precluded from doing because of your injuries?

What medical devices do you use to assist you?

Do any health care professionals provide you treatment in your home?

Does anyone assist you with your daily living needs?

Do you ever leave your home? How?

Has your health care insurance or medicaid/medicare paid your medical bills?

Have you altered your home in order to conduct your daily living activities? In what way(s)?

Have you received any assistance in performing your daily activities from family members? Have they been paid? Do they expect to be paid? How much?

Have your physicians told you how long you will be disabled?

Have you received any psychological care as a result of the accident?

Were you employed at the time of the accident?
Yes  No 

Did the accident happen while you were working?

Will you ever be able to return to the same type of employment?

Will you ever be able to return to restricted employment?

Copyright ©2009 FindLaw, a Thomson Business

DISCLAIMER: This site and any information contained herein are intended for informational purposes only and should not be construed as legal advice. Seek competent legal counsel for advice on any legal matter.

NOTE: Anindicates required information

Contact Information

Name Please enter a valid name.

E-mail Address Please enter a valid e-mail address.

Phone

How did you hear about us Please enter how you heard about us. Select one Article Internet Search My union Referral from an attorney Referral from a client Other (please specify below) Message

Please verify that you have read the disclaimer. I have read and
understand the disclaimer. disclaimer.

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

close