Case Review Form - Cronauer Law

Cronauer Law
Case Review Form

Answer the questions to the best of your memory, if you do not know the answer right now, you may skip the question.

Name

Email

Phone number

Date of the injury

City

Police Report Number

Please be as detailed as you can

Were Emergency Vehicles called to the scene?

Yes No I don't remember

Did anybody get a ticket?

Yes No I don't remember

Were you taken to the hospital by Ambulance?

Yes No I don't remember

What are your injuries?

Are you still being treated or have you been released from your healthcare professional?

I am still treating I was released

How long will it take to recover?

How much in medical bills do you have so far?

Do you have health insurance?

None Medicare Medicaid Personal Insurance

Any earnings or wages lost due to the injury? Did you have to miss work?

What did any other attorney say about your case (If you spoke to another attorney)

Information you submit is confidential and will only be used to evaluate your case.