Confidential Case Evaluation
Type of Case:

Medical Malpractice
Personal Injury 
Product Liability
Identity of Individual Reporting Injury:
First Name:
Last Name:
Street and Apt#:
City:
State:
Zip Code:
Email Address*:
Daytime phone:
Evening phone:
Fax number:
Information About Injured Person:
The following information is about myself: Yes No
If "No", my relationalship to patient is:
Identity of the Injured Person:
Full name:
Date of birth:
Occupation:
Marital status: Single Married
Month, day, year the injury occurred: 
City and state where the injury occurred: 
Please give a brief description of the injury, describing the nature of the injury and how you believe it came about:
Please list the names of the person, entity, doctors, hospitals and/or other health care providers you believe to be responsible for the injury:
Please describe any disability, lost wages, medical expenses and other damages resulting from the injury:
Legal Information:
Have you contacted other lawyers about your potential case? Yes No
If “Yes,” did any lawyer agree to represent you? Yes No
Are you still being represented by that lawyer? Yes No
Insurance Information:
Have you been contacted by the lawyer or insurance company for the person/doctor/hospital/other healthcare provider believed to be responsible for the injury? Yes No
Documents:

Do you have medical records, medical bills, or other related documents in your possession? Yes No

Other Information:
How did you hear about my practice?
How did you find my website?
Questions and Comments

Copyright Disclaimer

This Web page is a public source of general information. It is designed to be correct, complete and current but this cannot be guaranteed. It is not intended to be a source of legal advice, so anyone reading or making a submission to this Web page should not rely on information it contains as legal advice. Settlements or verdicts regarding cases discussed herein were obtained due to the particulars of those cases, and we cannot and do not guarantee similar results and verdicts for other cases. While we accept and welcome email, submission of the Confidential Case Evaluation form to Terry M. Word, P.C. does not create an attorney-client relationship. We will not accept requests for legal advice nor offer specific legal advice over the Internet.