Recovery Reply Form

In order to best advise you about the rights and resources available to you under Washington State personal injury law, please inform us as to the nature and circumstances involving your personal injury or accident. The information you provide will be held in the strictest confidence. It will enable an Adler Giersch professional to evaluate how we may be best able to assist you at this time and to understand as much as possible about your present condition before we meet. We appreciate the time and care to get in touch with us and look forward to conferring with you very soon.





Name*

Address

City

State

Zip Code

Email Address*

Daytime Phone

Evening Phone


Date of Personal Injury/Accident

Type of Accident

Year, Make and Model of Vehicle

Amount of your property damage, if applicable?

Do you have photos of the property damage?

YesNo

Was the vehicle towed?

YesNo

Have you had a medical exam for the injury?

YesNo

When was the date of the first health care provider appointment?

Who was the first health care provider?

How did the injury happen?

Describe the nature of the injuries.

Please add any other comments you think are significant about your situation.


Best Time to Contact You

AMPM

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