Dog Bite Client Intake | Phoenix Personal Injury Lawyer

Name *

First

Last

Email *

Cell Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date Of Birth (Month, Day, Year) *

Date / Time of the dog attack *

Date

Time

Is You Have

Describe How the attack took place *

Did The Police Come To The Scene *

Do You Have An Incident Report *

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

If you have the police report or incident report, please upload it here.

Did You Take Pictures Of Your Injuries *

Please Submit Photos Of Your Injuries.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Have You Recieved Any Professional Medical Attention *

Have you been treated by any medical professionals since the crash?

Please Describe Your Injuries To The Best Of Your Ability *

I don’t expect you to know your exact condition, but I would like to have some idea of what you believe your injuries are and where they are located.

Do You Know Who Owns The Dog(s)

List Their Name, Address, Phone, Email, Or Any Other Contact Information

Have You Filed A Claim With The Dog Owner's Insurance *

Have You Filed A Claim For This Attack With Your Insurance Company *

Please Put The Claim Information For The Dog Owner Here

The name of the insurance company, the name of the adjuster, the claim number, and the phone number if you have it.

Please Upload Any Photos, Documents, Or Anything You Thing Else You Think Is Important.

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

Please Write Down Any Details That You Think Are Important For Me To Know About

Please Provide An Emergency Contact *

Who can I contact if I have not heard from you in two weeks? List their name and their phone number.