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Personal Injury
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Atlanta Lawyer Group
1401 Peachtree St., N.E. Suite 240
Atlanta, Georgia, 30309
Office:
404-607-7100
Fax:
404-607-7121
Trucking Accidents
Car Accidents
Product Liability
Dog Bites
Trip and Fall
Wrongful Death
Personal Information
Your Name:*
Your Address:*
Email Address:*
Verify Email:*
Cell Phone:
Home Phone:
Office Phone:
Best Way to Contact You:
Victim Information
Relationship to Victim:
Victim's Name:
Victim's Age:
Victim's Occupation:
Victim - Single, Separated, Married, or Widowed:
Injury Details
Date of Injury:
/
/
Location (City and State) of Injury:
Describe the Victim’s Health Just Prior to the Injuries and then Describe the Injuries? If the Injuries are permanent, please describe how so.:
How has the Victim’s Life changed after the injuries? What things can the Victim no longer do?:
List The Doctors, Hospitals and Other Medical Providers Who Provided Medical Care:
Describe the Events that Caused the Injuries:
Witnesses (Name and Phone):
Final Information
I HAVE READ AND AGREE TO THE TERMS OF THE DISCLAIMER AND USE OF THIS EVALUATION FORM AS SET OUT
HERE
:
I AGREE
If you want to speak with someone in our office directly, please call 404-607-7100 (although filling out the form below would be very helpful to us).
All of your information will be kept strictly confidential.