Personal Injury Intake Form

McGowan, Hood & Felder LLC

Personal Injury Intake Form

NOTE: An asterisk (*) indicates REQUIRED information. 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.

*Name:   
Street Address:   
City:   
State:   
Zip:   
Phone:   
Fax:   
*Email Address:   
Date of Accident:   
 
How would you like to be contacted?
 Email
 Phone
     Fax
 Postal Mail
 
Were there injuries to anyone?
 Yes  No
   
 
Types of injuries / Brief description of accident: