Injury Intake Form

This page is for potential new clients. Please be sure to add correct information because if your case is accepted, we will use this information to prepare our retainer (terms for representation) for electronic signing. If your case is accepted, retainer and case documents will be sent to your email address for electronic signing using your smart phone. At Augustine Law Corp., we are selective and only take serious injury cases.

Name

First Last

Name of Deceased (If this is a wrongful death case.)

First Last

Your Date of Birth

Date of Injury/Incident

Type of Case

Name of Person at Fault

First Last

Email Address

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Summary of What Happened

Upload Pictures or Documents for Review

Max. file size: 100 MB.

Please upload any pictures or documents that are related to your case.