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In order to advise you about your 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.

Your Name:


Your Street Address:



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Your Daytime Phone:


Your Evening Phone:


Best Time to Contact You:

Your E-Mail Address:


Your E-Mail Address: (reenter to confirm)



"Your" Questions

Date of Personal Injury/Accident:


Type of Accident:


How Did The Injury Happen?:


Describe The Nature of the Injuries:


Have You Had a Medical Examination for the Injury?

Please Add Any Other Comments You Think Are Significant
About Your Situation:


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