Personal Injury
Free Case Evaluation
Atlanta Lawyer Group
1401 Peachtree St., N.E. Suite 240
Atlanta, Georgia, 30309

Office:404-607-7100
Fax:404-607-7121
Your Name:*
Your Address:*
Email Address:*
Verify Email:*
Cell Phone:
Home Phone:
Office Phone:
Best Way to Contact You:

Relationship to Victim:
Victim's Name:
Victim's Age:
Victim's Occupation:
Victim - Single, Separated, Married, or Widowed:

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):

I HAVE READ AND AGREE TO THE TERMS OF THE DISCLAIMER AND USE OF THIS EVALUATION FORM AS SET OUT HERE:

 

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.