PERSONAL INJURY INQUIRY

If you or a loved one has been injured due to the negligence of someone else, please provide the following information so we may review your matter and schedule an in-person consultation.

Submission of information through this form is for information purposes only, and to allow us to briefly review your potential case. Use of this form does not establish an engagement on your matter, and does not create an attorney-client relationship. Whether or not we accept your case, all information submitted is confidential and will never be shared outside the firm. If we accept your case, you will be provided with a formal "Letter of Engagement" establishing the rights and obligations associated with your case.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Date of Accident/Injury

MM

DD

YYYY

How Were You Injured?

Please briefly summarize how you were injured, by whom you were injured (if you know), where the accident took place, the nature and extent of your injuries, the names of anyone that was injured at the same time as you, the names of any witnesses, and any other information you believe to be relevant to your case.

Have You Seen a Doctor?

Yes

No

If Yes, Please List all Doctors and/or Hospitals

Disclaimer

I acknowledge that submitting this form does not create an attorney-client relationship, does not create or constitute a claim against any entity, and that I wish for a representative of Breslin Law Group to contact me by phone or email to discuss this matter further.

Yes