Orlando & Kopelman: Personal Injury Questionnaire

QUESTIONNAIRE

We would appreciate it if you would take a few moments by responding to the following questions. This will help us determine an appropriate course of action to take on your case. You do not need to answer these questions, and if you prefer, you may simply contact us at this point by calling (404) 373-1800. Please use our Toll Free number, 1-(866) 373-1800 if you are calling from outside of Georgia or the Metro Atlanta area. We look forward to hearing from you.

Please note that the information you provide will be kept confidential. We will not share your information with any other party without your permission.

Contact Information

First Name:


Home Address:


Home Phone:


Work Phone:


e-mail address:


Date of Birth:


Are you contacting us for yourself or on behalf of someone else:
Myself Someone Else

If you are contacting us on behalf of someone else, please provide that person’s name:


Type of Case

Were you involved in a: Motor Vehicle Collision Slip And Fall Trip And Fall Negligent Security (e.g., sexual assault, shooting, physical assault) Other (please describe briefly)
Date of Injury:


Miscellaneous

Have you consulted with another attorney:
Yes No

Do you already receive our firm newsletter:
Yes No

Would you like to receive our newsletter in the future?
Yes No