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Where To Turn When You’ve Been Wronged

Contact Marie A. Mattox, P.A.

While this website provides general information, it does not constitute legal advice. The best way to get guidance on your specific legal issue is to contact a lawyer. To schedule a meeting with an attorney, please call the firm or complete the intake form below.

Personal Injury Intake Form

Have you spoken to another attorney about this case?
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CLIENT INFORMATION

Client's Address

Address
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Spouse's Address

COLLISION/INCIDENT INFORMATION

DETAILS OF COLLISION/INCIDENT:

Did this injury occur when you were driving a vehicle?
Were you driving a company vehicle?
Was anyone, including yourself, to the best of your knowledge, taking any medications or using any sort of drugs?
Had anyone, including yourself, been drinking?
Did anyone make a statement at the scene?
Were photos/videos taken of the scene of the incident?
Were photos/videos taken of collision damage to vehicles?

INSURANCE COVERAGE FOR CLIENT/PLAINTIFF:

Carrier Address
Agent's Address
Are you covered through your employer's insurance?
Did you file a claim with your insurance company?
Has anyone from the insurance company contacted you about this claim?
Did you receive a copy?
Have you signed any authorizations to release information to anyone?
Have you signed any releases?
Have you received any insurance benefits?
Have you been judged by any administrative agency as paitially or permanently disabled as a result of this injury?

INSURANCE COVERAGE FOR DEFENDANT

Address
Agent's Address

Medical Information

Were you injured in this collision/incident?
Were photos/videos taken of injuries?
Were photos/videos taken of the injury causing instrument?
Did you go to the hospital?
Were X-Rays taken?
Were you taken by ambulance?
Are you under the care of a physician now?
Did you miss work due to the collision/incident?

List Doctors

Address
Physical therapy?
Address
Physical therapy?
Address
Physical therapy?
Address
Physical therapy?
Address
Physical therapy?

PRESCRIPTIONS: BRING IN ALL RECEIPTS, BILLS, ETC. NOTE USE OF CERVICAL COLLAR CASTS, WALKER, CRUTCHES, ETC. HA VE CLIENT BRING JN FOR EVIDENCE WHEN FINISHED USING OR WHEN CAST IS REMOVED.

Was anyone else injured?
Were photos/videos taken of injuries?
Were photos/videos taken of the injury causing instrument?
Did they go to the hospital?
Were X-Rays taken?
Were they taken by ambulance?
Are they under the care of a physician now?
Did they miss work due to the collision/incident?

Witnesses:

Address
Would they be willing to testify in court to what he/she saw?

Address
Would they be willing to testify in court to what he/she saw?

Address
Would they be willing to testify in court to what he/she saw?

Address
Would they be willing to testify in court to what he/she saw?

Address
Would they be willing to testify in court to what he/she saw?

VIEWING THE SCENE:

Can we go to the collision/incident scene?
Is the equipment available for inspection?
Address
Can we photograph the equipment?

DAMAGES:

How have your injuries changed your lifestyle:
Have you had to hire domestic help?
This field is for validation purposes and should be left unchanged.

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EMPLOYMENT INTAKE FORM
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PERSONAL INJURY INTAKE FORM