Missouri Personal Injury Lawyers - Wrongful Death Medical Malpractice - Kansas City Attorneys

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SUBMIT A FREE CASE REVIEW

Please fill out the following for a free case review. The information submitted will be accorded the utmost confidentiality. This information is necessary in order to do a conflict of interest check before responding to you. If you prefer, you may contact us at (660) 679-3161 or toll free (866) 601-3161.

Please provide the following information for the person in need of assistance. Note that information marked with a red asterisk (*) is required.

*First Name

*Last Name

* Date of birth

* Street Address

* City

* State

* Zip Code

E-Mail

* Home Phone

Other Phone

Marital Status

	Married
	Single
	Separated
	Divorced
	Widowed

Name of Spouse, if any

Occupation

Highest level of education attained

	High School
	Some College
	4 Year Degree
	Advanced Degree

Please provide a brief overview of the legal matter you need assistance with

Injury Cases

If you need assistance with an injury matter (including wrongful death claims, product liability claims and malpractice claims) please submit the following information as well.

City and State in which you were injured

Name(s) of the person(s) who you allege caused you injury, and their addresses, if known

Please describe your injuries

Please describe any treatment you have had so far

Are you still being treated for your injuries?

	Yes
	No

If yes, what kind of treatment are you now getting and/or do you anticipate in the future?

What is the approximate amount of your medical bills thus far?

Have you been forced to miss work due to your injuries?

	Yes
	No

If so, how much in lost wages and/or benefits have you sustained?

Have you been contacted by any insurance company regarding your injuries?

	Yes
	No

If so, what is the name and address of the insurance company and adjuster(s) you have talked to?

Are you currently represented by another lawyer?

	Yes
	No

If so, please give us the attorney’s name, address and phone number

If you Are Not The Injured Party

If you have filled this information out for someone else, and are not the person in need of assistance, please answer the following:

First name

Last name

Street address

City

State

Zip Code

E-Mail

Home Phone

Other Phone

Please describe your relationship to the person in need of assistance (e.g. parent, spouse, friend)

For Parents or Guardians

If the person in need of assistance is not a minor or disabled, we will need to communicate directly with that person regarding our review, in order to maintain attorney/client confidentiality. If the person in need of assistance is a minor or is a disabled adult with an appointed guardian we will need to communicate with that parent or guardian. With this in mind:

* Who is the person to be contacted after we have completed our review?

* What is the best time to contact that person?

* What is the best way to contact that person? (e.g., e-mail, phone, letter)

After the information is complete, please press the submit button. We will review the information and contact you as soon as we have done a conflict of interest check.

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Missouri Lawyers Disclaimer: The Missouri personal injury, wrongful death, medical malpractice, accident, serious injury and/or other legal information offered herein by the Law Offices of Stephen K. Nordyke, Missouri Attorneys, is not formal legal advice nor the formation of an attorney client relationship. Any results set forth here were dependent on the facts of that case and the results will differ from case to case. Please contact a Missouri Lawyer at our Kansas City and Butler offices.