Brian Lee Law Firm Client Intake Form

BRIAN LEE LAW FIRM, PLLC.

Plaintiff's Personal Injury Case Forms

The information contained in this questionnaire is for the use of our office only for the evaluation and preparation of your claim. The answers you give will be held in strict confidence and will not be released to unauthorized persons.

Please answer every question that applies to you fully and accurately. If more space is needed, use the reverse side of the page.

Today's Date:___________

PART I. PERSONAL DATA

Your Full Name:_____________________________________________

Street Address:______________________________________________

City, State, Zip:______________________________________________

Home Telephone:__________________________ Cell Telephone:_____________________

Your Age:________ Date of Birth:______________ SS#____________________

Dominant Hand:_____________

Spouse's Full Name:____________________________________________________________

Age:_____ Date of Birth:_______________ SS#____________________

How did you hear of this office?__________________________________________________

PART II. ACCIDENT/INCIDENT INFORMATION

Date:__________ Time:____________AM PM City/State:____________________

Specific Location:______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

How did the accident happen:

______________________________________________________________________________

______________________________________________________________________________

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