Personal Injury Case Evaluation Review Form

Please use this form if you would like for us to review your information in connection with your potential personal injury claim (e.g., admiralty/maritime, birth injury/defect, pharmaceutical, product, or toxic exposure case). NOTE: An asterisk (*) indicates REQUIRED information on any form. Thanks again, Gooch Law Firm.

Name and Contact Information of Injured

First Name: *

Last Name: *

Street Address: *

City: *

State: *

Zip Code: *

Country:

Telephone Number - Day: *

Telephone Number - Night: *

E-mail Address: *

What is your Date of Birth?: *

What is the best method to use to contact you?: *

General Case Information

Case Type: *

Please choose a case type from the following list. After you have chosen your particular case type, please go to the appropriate section to complete the questions related to your particular case type. For example, if your case involves a birth injury, please complete the birth injury section too. Thanks again.

Please tell us what type of injury you sustained, and briefly describe your accident/injury.: *

When did you sustain your injury?: *

Where did your injury occur (city, county & state)?: *

Did the accident/injury happen while you were at work?: *

Other comments?:

Questions regarding any Doctor Visits

Did you visit a doctor for your injury?: *

Did the doctor give you a diagnosis or diagnose an injury?: *

If you received a diagnosis, please tell us the diagnosis and the date of the diagnosis.: *

Are you still seeing a doctor for your injury?: *

Any additional comments?:

Admiralty/Maritime Injury Case Information

Please read and fill out this area if your personal injury case involves an admiralty or maritime accident or injury.

Please choose your industry/profession when the accident/injury occurred.:

If "other" chosen, please explain your occupation when the accident/injury happened.:

Birth Injury Case Information

Please read and fill out this are if your case pertains to a birth injury.

Please choose a case type.:

Please tell us the date of birth of your child.:

Please tell us what your relationship is with the injured.:

If you are serving in a representative capacity for a child, please give us your full name, address and telephone number.:

Other comments?:

Personal Injury Case Information

Case Type:

Please choose your case type. If you do not see your case type, please choose "Other" or go to the appropriate section on this form, e.g., Birth injury, Pharmaceutical Injury, etc.). Thanks again.

Other comments?:

Pharmaceutical (Drug) Case Information

Please read and fill out this area if your case pertains to a pharmaceutical injury.

What pharmaceutical (drug) do you believe caused your injury?:

When were you prescribed this particular drug?:

When did you start taking this particular drug?:

When did you stop taking this particular drug?:

Other comments?:

Product Liability Case Information

What type of product do you believe caused your injury?:

If you were implanted with a product/device, please tell us the date of the implant.:

If you were prescribed any medication in connection with your device, please tell us the name of the medication.:

If you were prescribed medication, please tell us your start date, stop date or if you are still on it.:

Toxic Exposure Case Information

Please read and fill out this area if your case relates to a toxic exposure.

What type of Toxic Exposure do you think may have caused your injury?:

When do you believe you were exposed to this toxic substance (please give us a date or range of dates)?:

Do you believe you may have been exposed to this toxic substance at work?:

If you believe you may have been exposed at work, please let us know the following:

What was your occupation during exposure and how long did you work at this job (please give us specific dates or ranges)?:

In what City, County and State were you employed when you were injured?:

Other comments?:

Wrongful Death Case Information

Please use this section if you are considering a wrongful death claim and you are a representative of the estate. Thanks again.

Representative capacity?:

If you are serving in a representative capacity of the estate, please give us your full name, address and telephone number.:

Was an autopsy performed?:

Do you have a copy of the autopsy?:

Do you have a copy of the death certificate?:

Other comments?:

Disclaimers and Notices

I agree that submitting this form and the information contained within does not create an attorney client relationship.: *

I confirm that I have read the disclaimer and privacy policy of the Gooch Law Firm, and the following Notice.: *

Notice - By submitting this form, you agree that you have read and consent to this notice, and to the Mollom privacy policy.: *

Please use this form if you would like for us to review your information in connection with your potential personal injury claim. Please note: Completion of this form does not contractually obligate our firm to represent you. We can only serve as your attorney if both you and our firm agree, in writing, that we will serve as your counsel. You agree, acknowledge and consent that this matter may be reviewed by more than one lawyer or law firm (other than our firm) and may be associated with or referred to another attorney or law firm who may contact you. You agree that this submission does not constitute a request for legal advice and that you are not forming an attorney client relationship by submitting this question or communication. You understand that you may only retain an attorney by entering into a fee agreement, and that you are not hereby entering into a fee agreement. You agree that the information that you will receive in response to the above question is general information and you will not be charged for the response to this e-mail question. You further understand that the law for each state may vary, and therefore, you will not rely upon this information as legal advice. Since this matter may require advice regarding your home state, you agree, acknowledge and consent that this matter may be reviewed by more than one lawyer or law firm (other than our firm), and local counsel (another lawyer or law firm) may be contacted by our firm for review of, association with or referral of this matter and that local counsel may contact you. Please read our disclaimer and privacy policy, and by submitting this submission/form/e-mail/other communication, you agree that you consent to and have read our disclaimer, privacy policy and this notice. In addition, the use of the Internet or e-mail, for this form, communication or any of the forms provided for communication with the firm or any individual member of the firm does not establish an attorney-client relationship, and you acknowledge that any reliance on material in email or communications is at your own risk. Confidential or time-sensitive information should not be sent through this form, e-mail or communication. NOTE: An asterisk (*) indicates REQUIRED information on any form. Thanks again, Gooch Law Firm.

Are you currently represented by an Attorney for this matter or for any other matter?: *

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Gooch Law Firm

Personal Injury Case Evaluation Review Form

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