IntakeBradshaw Law Office2024-08-18T13:30:08-05:00 We have allied attorneys in all 50 states.Where did this occur/happen? "*" indicates required fields In what state did this occur?*Select an AnswerMissouriKansas CitySpringfieldSt LouisJoplinAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonDistrict of ColumbiaWest VirginiaWisconsinWyomingCity/Town More specifics if available. Free Case Review | Welcome! Let’s get started.~Confirm~ the ~type of case~ causing your injuriesWhat type of injury is your case? Semi-Truck Wreck Injuries Birth Trauma, Cerebral Palsy, & Medical Malpractice Car Wreck Injuries Motorcycle Injuries ATV / UTV Injuries Aviation Injuries Boating & Water Injuries Burns & Electrical Injuries Dangerous Drugs & Medical Devices Medical Malpractice Nursing Home Injuries Premises Liability Products Liability Spinal Cord, Brain Injuries, & Amputations Workers’ Compensation Wrongful Death Other Personal Injuries Who was the person injured?~Who~ was the person injured?* Myself Someone else Your Name* Your First Name Your Last Name Your Name* Your First Name Your Last Name Name of Injured Person* Their First Name Their Last Name Their relationship to you* Did the injury involve any of the following?* Amputation Failure to timely diagnose cancer Surgery error or post-surgical error Brain damage Death A need for long-term medical care, or long-term assistance Other Other relevant information you want to provide us Name of at-fault medical-provider/entity if you know Name of hospital/clinic/facility where incident occurred Whose baby was injured?* My baby Someone else's baby Your Name* Your First Name Your Last Name Your Name* Your First Name Your Last Name Name of injured baby's mom/parent* First Name Last Name Their relationship to you* Did the injury result in any of the following?* Hospitalization of one night or longer Surgery required Emergency Room Visit Referral to a Specialist Future Medical Care Needed Primary care visit one time or more Physical Therapy Chiropractor Treatment Skin Grafts Required Death Other Select all that applyDid your baby require or have any of the following...* Delivery by Emergency C-section Vaginal delivery with use of Forceps or a Vacuum Admission to the PICU (pediatric intensive care unit) for up to 5 days Admission to the PICU (pediatric intensive care unit) for MORE than 5 days Had one or more seizures Required a feeding tube or G-tube Had a low heart rate before birth, or Fetal Distress Have a shoulder dystocia May have HIE (hypoxic ischemic encephalopathy) Underwent a brain Ultrasound and/or MRI Has Cerebral Palsy Had low Apgar scores Did the injury result in any of the following? Spinal Cord Injury Brain Injury Amputation Did the injury result in any of the following? Amputation Failure to timely diagnose cancer Surgery error or post-surgical error Brain damage Death A need for long-term medical care, or long-term assistance Other Other relevant information you want to provide usType of Cancer How long was the delay in diagnosis? Less than 6 months More than 6 months but less than a year More than a year Did this happen in the last 180 days? Yes No I don't remember Please be as specific as you can.When did the injury happen?DayPlease select the day12345678910111213141516171819202122232425262728293031MonthPlease select the monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYearPlease select the year2024202320222021202020192018201720162015201420132012If you cannot remember the day, give us month and year.If you cannot remember what month or year, please call our office (888)775-000 When did the birth occur?DayPlease select the day12345678910111213141516171819202122232425262728293031MonthPlease select the monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYearPlease select the year202320222021202020192018201720162015201420132012If you cannot remember the day, give us month and year.If you cannot remember what month or year, please call our office (888)775-000 When did the wrongful death happen?DayPlease select the day12345678910111213141516171819202122232425262728293031MonthPlease select the monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYearPlease select the year202320222021202020192018201720162015201420132012If you cannot remember the day, give us month and year.If you cannot remember what month or year, please call our office (888)775-000 How did the wrongful death happen? In summary, how did the wreck happen? Please be as specific as you can.What went wrong, if you have an idea or anyone told you? Please be as specific as you can.How did the injury happen? Please be as specific as you can.Please describe the injury. Please be as specific as you can.What type of product caused the injury? Please be as specific as you can.How do you believe the product was defective or unreasonably dangerous? Please be as specific as you can.Do you know the name of the at-fault semi-truck company? Please be as specific as you can.Body of water was involved in the injury? (Name of lake, river, bay, etc.)Body of Water Please be as specific as you can.Type of watercraft(s) was involved in the injury? Please be as specific as you can.Name of at-fault medical-provider/entity if you know.Name of hospital/clinic/facility where incident occurred. Select all that apply.A citation/ticket was issued toPlease select any that apply to the incident: Another vehicle/driver Me Nobody Unsure I was a passenger Please provide the employer information.Name of Employer AddressEmployer Address & State Street Address City State / Province / Region ZIP / Postal Code Was the employer notified of the injury? Yes, immediately Yes, within 24 hours Yes, within 30 days No Is employer/employer-insurance paying for medical care? Yes No Has the injury resulted in... A change in job duties/accommodations More than 3 days off work Tell us about the birthWas this your first child?Was this your first child? Yes No How many weeks along was the pregnancy at birth, best estimate?How many weeks along was the pregnancy at birth, best estimate? Less than 36 weeks 36 – 40 weeks More than 40 weeks What was the baby’s birth weight, best estimate?What was the baby’s birth weight, best estimate? Deceased InformationDeceased First & Last NameDeceased Information* First Last Your relationship to the deceased* Other relevant information you want to provide us...Relevant Information Almost done just a few more details.Let us know the best way to reach you.Name* First Last Your Phone Number*Your Email Address* Your Mailing Address* Your Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code NameThis field is for validation purposes and should be left unchanged.
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