If you would like a NO COST initial consultation, please answer the questions below to the best of your ability. The more detailed info you provide the better we will be able to discuss your matter with you.

Your First Name:
Your Last Name:
Phone Number:
Email Address:
Alternate Number / Message Number:
Is this inquiry about you or someone else?
If someone else, what is your relationship to the injured worker?

THE FOLLOWING REQUESTED INFO RELATES TO THE INJURED WORKER.

Name:
Address:
City:
State:
Zip Code:
Phone Number:
Alternate Number / Message Number:
Date of Injury:
Date of Injury Employer:
Wage rate at time of injury:
Present work status based upon your treating doctor’s opinion:	No work   restricted / light work    regular work
Work restrictions (such as no use of left hand):
Part(s) of body injured:
Name(s) of your treating doctor(s):
Have you had any surgeries performed because of your injury?
Present status of claim:
Denied:	Yes   No If so, date of denial:
Accepted:	Yes   No
Open for active care:
Hearing pending regarding any issue?	Yes   No
Hearing date:
Current issue(s) / questions:

  I understand that submitting this form does not create an attorney-client relationship. I further understand that responses to my inquiry SHOULD NOT BE CONSIDERED SPECIFIC LEGAL ADVICE AND MAY NOT BE RELIED ON FOR MY INDIVIDUAL CASE. I understand that the lawyers at SCHIFFMAN LAW OFFICE, P.C. have not agreed to represent me by responding to initial or follow-up inquiries and prior to legal representation both the client and an attorney of the firm must sign a fee agreement and a formal notice of representation or appearance. I understand that the lawyers at SCHIFFMAN LAW OFFICE, P.C. do not presently have enough detailed information about the status of my particular matter and that I remain responsible for meeting any deadlines or statutes of limitation until an attorney of the firm has formally agreed to represent me and entered an appearance in my specific matter.

We respect your privacy. The info you provide will be kept confidential. Thanks for your inquiry.