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CASE REVIEW

WE'LL GET RIGHT BACK TO YOU

Please complete and submit the “Case Review” form below (est. time 5 minutes).

The information you provide will form the basis of our prelimary assessment of your case. A Manaster Law Firm PLLC attorney will personally review the material. They, or someone with our staff, will contact you shortly thereafter to you to discuss next steps

Case Review

Name *

Name

First

First

Last

Last

Email *

Phone *

Address *

Case type * Case type

Date of Incident *

Was the accident your fault? *

Yes

No

Was a police or accident report made? *

Yes

No

Unsure

Were you physically injured or in pain? *

Yes

No

Identify all injured body regions *

Brain

Head

Face

Neck

Spine

Vertebra

Chest (thorax)

Abdomen

Genitalia

Pelvic organ

Lower back and pelvis

Pelvic girdle

Buttock

Shoulder and upper arm

Forearm and elbow

Wrist, hand, and fingers

Other part of arm

Hip

Upper leg and thigh

Knee

Lower leg and ankle

Foot and toes

Ankle and foot

Unclassifiable by body region

Systemwide

OtherOther

Identify all injury types *

Fracture

Dislocation

Sprain or strain

Internal organ injury

Open wound (abrasion, puncture, etc.)

Contusion or bruise

Superficial injury

Crushing

Amputation

Blood vessel

Burn

Corrosion (chemical burn)

Effect of foreign body entering orificae

Other effect of external causes

Injury to nerves

Injury to muscles or tendons

Poisoning

Toxic effects

Mental or emotional

OtherOther

Does anyone have auto insurance coverage? *

Yes

No

Unsure

Were you taken from the incident by ambulance to ER? *

Yes

No

Were you hospitalized other than visiting ER? *

Yes

No

Did you receive medical treatment? *

Yes

No

Did you miss work? *

Yes

No

Did you have surgery? *

Yes

No

Is an attorney helping you with your claim or has an attorney already rejected your claim?

Yes

No

Approximately how much are your medical expenses so far?

Please describe the incident in question. *

If you are human, leave this field blank.

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MANASTER LAW FIRM PLLC
8350 N Central Expy, Suite 1900
DALLAS, TEXAS 75240

469.415.4555 tel
469.915.6465 fax

[email protected]

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This website and its contents are for general information purposes only. Nothing on this site should be taken as legal advice for any individual case or situation. Nothing is intended to create an attorney-client relationship and none shall be created here.

CASE REVIEW

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