Case Evaluation

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. Please provide the following information for the person in need of assistance. Fields with (*) are required.

*Full Name

*Street Address

*City, State, Zip

*E-Mail

*Home Phone

Other Phone

Occupation

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.

Date and Place of Injury.

How were you injured?

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 best time to contact you?

What is the best way to contact you? (e-mail, phone, letter)

After the information is complete, please press the submit button. Mr. Buchta will review the information and contact you within 24 hours with his evaluation