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 of Deceased (If this is a wrongful death case.)
MM slash DD slash YYYY
MM slash DD slash YYYY
Name of Person at Fault
Max. file size: 100 MB.
Please upload any pictures or documents that are related to your case.