Personal Injury Form
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1BHURTEL LAW FIRM PLLC ‘s (Use this Form if you have personal injury/medical mal question)
URL: Phone no: 785096181 Email:
)
Today’s Date:
PART 1: Name: Last: …………………………
First:……………………………….
Middle:…………………
1. Address
Street ___________________________________
Apt No_____
City ___________
State ____________
Zip Code _________
Home Phone:
____________
Mobile : _______________
Email:
I prefer to be notified by email. Yes ( ) No( )
2. Do you have appointment today?
a. Yes ( ) If yes, time of appointment: ________ No b. ( ) ___________
3. How did you find our office: a. ( ) I knew myself b. ( ) News Paper c. ( ) Internet d. ( ) other
Name of source send you:
Part 2-------------------------------------------------------------------------------------------------------------------------------
4. Date of incident or accident:
5. Address of accident or place of accident:
6. Describe how did happened?
7. Injuries or body part involved:
8. Name of Employer:
9. Address of Employer:
10. Name and address of hospital visited:
11. Date of hospital or doctor visited:
12. I was advised that Bhurtel Law Firm is unable to represent me.
13. I need to find immediately another lawyer if I want to pursue for my matters, claim or represent me.
14.
Signature of person in Part 1: __________________
Taken By:
Next Appointment:
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Parent category: Business