Office nearest you: Atlanta Macon Columbus *

How were you referred to this office?

Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Work Phone

Home Phone/ Mobile Phone *

E-mail *

Which of the following applies to your situation: Make a selection Car Accident Slip and Fall Medical Malpractice Wrongful Death Workers' Compensation Other *

Do you have a copy of the incident report? Yes No

What was the date of the incident? ... *

Who was at fault on the incident report?

Please briefly explain the incident. *

Who was the driver of your vehicle?

Were there any passengers? Yes No Does not apply

Was anyone else hurt? Yes No

How were you injured?

Did you go to the emergency room? Yes No

If yes to the previous question, what ER did you go to?

Have you seen any other doctors? Yes No

If yes to the previous question, list the physicians below

What was the name of the at-fault person's insurance?

What is the name of your insurance company?

Do you have medical payments coverage? Yes No

Please list any additional important information below.