Lucas Green & Magazine - Consultation Form for New Port Richey Attorney

New Port Richey Injury Lawyer Consult Form
For a free, no-obligation consultation with an experienced New Port Richey personal injury attorney at Lucas, Green, & Magazine regarding your case, please submit the following response form. We will respect the confidentiality of your information to the fullest extent. Form submissions are relayed to us through our highly secure servers.

Tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be communicated with anyone. It is necessary only for purposes of enabling us to do a conflict of interest check prior to responding to you. We cannot respond without being able to do our conflict check. Email Field is required.

First Name

*Last Name

*Number, Street & Apt.

City

State

Zip

Email

Day Phone

Night Phone

Please provide a brief personal background of the person needing assistance. Many times we are contacted by someone other than the person in need of help, such as a parent on behalf of a child, or wife on behalf of a husband. Please provide the following information on behalf of the person who needs assistance.


The following information is for myself: Yes No
Yes No

If "No" my relationship to the following person is:

First Name

Last Name

Age

Occupation

For how long?

Current or last employed?

City and State where last employed

Highest grade completed

Schools/Colleges Attended

Degrees

Year degree granted

Special training or experience in

Why do you need help? Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request. You can provide more detailed information below, but for now please confine yourself to providing us with a brief statement of the general facts of your case, injury and damages.



State the date you were injured or when you first learned that you had been injured?

What occurred?

Where did it happen? Please type in the City, County and State where it happened:
City
State
County

Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:


What damages were suffered? Describe the damage you have suffered:


Has anyone already filed a suit?
Yes No Please make a selection.

When is the best time to reach you by telephone?


When the information you have provided is complete, please press the Submit button below to send it to . Your information will be kept strictly confidential.


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