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Case Evaluation Form

Name:
Street Address:
Address (Cont.):
City:
State/Province:
Zip/Postal Code:
Work Phone:
Home Phone:
Fax:
Email:
 
Have you seen a doctor about your situation?

Yes
No

Have you consulted an attorney about this case previously? Yes
No

 

 

Please provide some details about your situation:
(maximum of 7,500 characters)
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I agree that this matter may be referred to an attorney in my area who may contact me.
Yes No

I agree that by submitting this form, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.
Yes No

I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this form. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.
Yes

 


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