PERSONAL INJURY INTAKE FORM – Kirk F. Lechtenberger

PERSONAL INJURY INTAKE

***PLEASE EMAIL ANY PHOTOGRAPHS, OR BILLS IN YOUR POSSESSION RELATED TO THE ACCIDENT TO [email protected]

IF INTERVIEWED, INTERVIEWER NAME:

ARE YOU CURRENTLY REPRESENTED? *

HOW DID YOU HEAR ABOUT US? *

Email Address (YOU WILL RECEIVE A CONFIRMATION OF THIS INTAKE) *

NAME *

First

Last

SSN *

SEX *

MALE
FEMALE

EDUCATION

HIGHEST LEVEL

COUNTY *

PHONE (MAIN) *

PHONE (WORK)

MARRIED *

INVOLVED CHILDREN

List your children who were involved in the accident: Include the name, age, sex, dob, and social security number.

EMPLOYMENT (HAVE YOU MISSED WORK AS A RESULT OF THE ACCIDENT?) *

HOW MANY DAYS MISSED

OCCUPATION

WAGE / SALARY

EMPLOYER

TELEPHONE NUMBER

CITY / STATE OF EMPLOYER

SUPERVISOR NAME

NON-SOLICITATION ACKNOWLEDGEMENT *

I ACKNOWLEDGE

I, the undersigned herby state that I am of sound mind, competent and have the authority to sign this Non- Solicitation Acknowledgment. I have not been solicited, coerced, or promised money or anything of value by Kirk F. Lechtenberger, LLC, or its agents, employees, or representatives. I am aware that Kirk F. Lechtenberger, LLC is licensed in Texas, and may hire local counsel or make a referral. No independent contractor, agents, employees or representatives that are not attorneys. I realize that I have the right to choose any attorney to represent me in this matter and have chosen Kirk F. Lechtenberger, LLC to represent me as evidenced by the signed contract attached hereto. If I am completing the online intake form I understand and agree that my electronic signature is legal and enforceable as a traditional Acknowledgment signed in ink. I have read, understand, agree and accept this Acknowledgement, I chose Kirk F. Lechtenberger, LLC, of my own free will, voluntarily, and without compensation or anything else of value. My electronic signature below confirms this.

Electronic Signature (Please type name after /s/) *

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