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PERSONAL INJURY INTAKE FORM
PERSONAL INJURY INTAKE
***PLEASE EMAIL ANY PHOTOGRAPHS, OR BILLS IN YOUR POSSESSION RELATED TO THE ACCIDENT TO info@lechtenberger.net
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IF INTERVIEWED, INTERVIEWER NAME:
ARE YOU CURRENTLY REPRESENTED?
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YES
NO
HOW DID YOU HEAR ABOUT US?
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Email Address (YOU WILL RECEIVE A CONFIRMATION OF THIS INTAKE)
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NAME
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First
Last
SSN
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SEX
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MALE
FEMALE
EDUCATION
HIGHEST LEVEL
COUNTY
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PHONE (MAIN)
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PHONE (WORK)
MARRIED
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YES
NO
INVOLVED CHILDREN
List your children who were involved in the accident: Include the name, age, sex, dob, and social security number.
EMPLOYMENT (HAVE YOU MISSED WORK AS A RESULT OF THE ACCIDENT?)
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YES
NO
HOW MANY DAYS MISSED
OCCUPATION
WAGE / SALARY
EMPLOYER
TELEPHONE NUMBER
CITY / STATE OF EMPLOYER
SUPERVISOR NAME
NON-SOLICITATION ACKNOWLEDGEMENT
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I ACKNOWLEDGE
I, the undersigned herby state that I am of sound mind, competent and have the authority to sign this Non- Solicitation Acknowledgment. I have not been solicited, coerced, or promised money or anything of value by Kirk F. Lechtenberger, LLC, or its agents, employees, or representatives. I am aware that Kirk F. Lechtenberger, LLC is licensed in Texas, and may hire local counsel or make a referral. No independent contractor, agents, employees or representatives that are not attorneys. I realize that I have the right to choose any attorney to represent me in this matter and have chosen Kirk F. Lechtenberger, LLC to represent me as evidenced by the signed contract attached hereto. If I am completing the online intake form I understand and agree that my electronic signature is legal and enforceable as a traditional Acknowledgment signed in ink. I have read, understand, agree and accept this Acknowledgement, I chose Kirk F. Lechtenberger, LLC, of my own free will, voluntarily, and without compensation or anything else of value. My electronic signature below confirms this.
Electronic Signature (Please type name after /s/)
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