Personal Injury Case Evaluation

Friday, May 16, 2008

Personal Injury Talk Lines - Listen to Personal Injury Information

Personal Injury
Product Liability
Medical Malpractice
Birth Injuries
Auto Accidents
Motorcycle Accidents
Truck Accidents
Drunk Driving Accidents
Dog Bites
Wrongful Death
Nursing Home Neglect
Drugs & Medical Devices
Vioxx
Risperdal
Bextra
Celebrex
Prempro/HRT
Zyprexa
Seroquel

Personal Injury Case Evaluation

1. What is your full name, address, telephone number, and email address.

*Name:

*Address:

*City:

*State:

*Zip:

*Home Phone:

*E-mail address:

*Date of birth:

2. If you are not the injured indivdual, please state your relationship to the injured individual and the injured individual's full name address, telephone number, email address and date of birth.

Relationship:

Injured person's full name:

Address:

City:

State:

Zip:

Telephone number:

E-mail address:

3. Please briefly describe the incident or accident that you are calling about? What happened?

4. Where did the incident happen and on what date?

Where:

What date:

5. What injuries did the injured individual suffer solely as a result of the incident.? Be as detailed as possible.

6. Did the injured individual see a physician or healthcare provider with twenty four (24) hours of the incident?
Yes No

7. Has the injured individual ever before sustained similar injuries.
Yes No

8. Is the injured individual still seeing a physician?
Yes No

9. Does the injured individual have insurance which is paying medical bills? If so, with what carrier?
Yes No

Carrier

10. Has the injured individual:
A. Lost time from work because of the injuries;
B. Lost the ability to work because of the injuries.

11. If this was a motor vehicle accident:
A. Was the injured individual wearing a seatbelt;
B. Has the damage to the vehicle been repaired.

12. Who do you believe is responsible for the incident and the injuries the injured individual has suffered and why?

13. If you believe a product caused the incident or the injuries suffered by the injured individual, please identify the product and please tell us if you still possess the product.

14. Were there eywitnesses to the incident and if so, do you have their names and addresses?
Yes No

15. Was the incident investigated by the law enforcement, and if so, do you have a copy of the investigation report?
Investigated
Yes No

Copy of investigative report
Yes No

16. Do you have photographs of the incident or the injured individual?
Yes No

17. Has the injured individual previously retained an attorney on this matter?
Yes No

Arlington 2216 S. Cooper Arlington, TX 76013 817.276.6000 View Map	Bedford 1900 W. Airport Freeway Bedford, TX 76022 817.868.5500 View Map	Dallas 4131 N. Central Expressway, Suite 860 Dallas, TX 75204 214.252.9099 View Map	Fort Worth 4747 S. Hulen #100 Fort Worth, TX 76132 817.263.3000 View Map

Grand Prairie 2304 W. Bardin Road Grand Prairie, TX 75052 972.642.7900 View Map	Irving 3401 W. Airport Freeway Suite 216 Irving, TX 75062 972.256.6300 View Map	Plano 5700 W. Plano Parkway Suite 100 Plano, TX 75093 866.378.4705 *By Appointment Only View Map	Weatherford 206 Houston Avenue Weatherford, TX 76086 817.594.5428 View Map

Houston Clear Lake/Nasa 18333 Egret Bay Blvd Houston, TX 77058 281.335.7744 View Map	Galleria Office 2425 West Loop South Suite 200 Houston, TX 77027 713.335.5577 *By Appointment Only View Map	Westchase Office 9801 Westheimer Suite 302 Houston, TX 77042 713.335.5577 *By Appointment Only View Map	Woodlands Office 2203 Timberloch Place Suite 100 Houston, TX 77380 713.335.5577 *By Appointment Only View Map

Brownsville 2200 Boca Chica Blvd. Suite 120 Brownsville, TX 78521 956.504.6611 View Map	Harlingen 1713 E. Tyler Ste D Harlingen, TX 78550 956.440.0534 View Map	McAllen 5415 N. McColl McAllen, TX 78504 956.686.5500 View Map

Tampa 2202 N. West Shore Suite 200 Tampa, FL 33607 813.221.0212 *By Appointment Only View Map	Orlando 7380 Sand Lake Road 5th Floor Orlando, TX 32817 407.351.2302 *By Appointment Only View Map	W. Palm Beach 301 Clematis Street Suite 3000 W. Palm Beach, FL 33401 561.832.5022 *By Appointment Only View Map	Miami 5201 Blue Lagoon Dr Miami, FL 33126 305.716.9066 *By Appointment Only View Map


St. Louis 111 West Port Plaza Suite 250, Bldg 200 St. Louis, MO 63146 314.628.9824 *By Appointment Only View Map	Kansas City 2300 Main St Kansas City, MO 64108 816.471.5842 *By Appointment Only View Map

*Ben Tompkins - Board Certified Personal Injury Trial Law
Texas Board of Legal Specialization

**John Robinson & Martin Miller - Board Certified Criminal Trial Law
Texas Board of Legal Specialization

***Keith Spencer – Board Certified Family Law
Texas Board of Legal Specialization

Personal Injury: No attorney fees unless you recover. Court cost, litigation expenses and medical bills are paid from your share of the recovery. If there is no recovery, you will not be responsible for any court cost or litigation expenses, except unpaid medical. Consultation in the Houston Galleria, Plano, Westchase, Woodlands, Florida and Missouri offices by appointment only. Principal office located in Bedford, Texas. Bailey & Galyen Attorneys at Law is a dba of Phillip Galyen, P.C.