201 E. Kennedy Blvd. Suite 1475 Tampa, FL 33602

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Personal Injury Case Evaluation

Please answer as many of the following questions as you can.

Name:
Address:
City:
State:
Zip Code:
Email Address:
Phone Number:
When were you injured?
How did the accident/injury occur?
Where did the event occur?
Was the accident/injury work-related?	Yes No
Were there any witnesses to the occurrence?	Yes No
Was an investigation conducted (property owner, police, or anyone else)?	Yes No
Did you do anything to cause the accident?
Was there anything that could have been done to avoid the accident?
Did you know any of the parties involved, prior to the accident?
When did you first receive medical care for your injuries?
When did you first receive medical care for your injuries?
What was your diagnosis? Prognosis?
What treatment have you received?
How has your life changed as a result of the accident?

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Address: Fifth Third Center 201 E. Kennedy Blvd, Suite 1475 Tampa, FL 33602 Toll Free: 877-888-JURY Phone: 813-223-7799