Your full name:

E-mail Address:
  (Required)

Mailing Address:

Home Number:

Work Number:

Best time to reach you:

Who was injured?

Is the injured party deceased?

If so, date of death?

Date of Injury?

Name of Facility?

Location of Injury?

Describe the incident(s) which caused the injury as fully as possible:

Who do you believe was at fault in causing the injury, and what do you believe they did wrong?

Do you have any other information which you believe would help us help you?

Describe the injuries. If you know, state whether the injuries are permanent. If you know, what are the total medical bills to date?

Are there any photographs of the injuries?

Has the injured party suffered any other losses because of this injury and, if so, please describe the losses:

Is there a living spouse?

If so, spouse's name:

Is there a Power of Attorney?

Are there any other questions you wish answered?

Is there any other information that you want to provide us?

Would you like to arrange an in office interview?

Are there any other instructions you wish to give us?

Final Instructions

INTERNET SECURITY: Sending information over the internet is not always a secure way to send information. While we will keep the information you send us over the internet CONFIDENTIAL once it is received in our office, we cannot be assured that it will be secure while being transmitted to our office. If you have any concerns about that, please print the information above and mail it to us at:

Wagner, Vaughan & McLaughlin, P.A.
601 Bayshore Boulevard
Suite 910
Tampa, Florida, 33606

THE SERVICE WE PROVIDE: When we receive the information you have provided, we will evaluate the information and then contact you by telephone or by mail at the address and phone number you have given us to tell you:

a. Our preliminary evaluation of the merits of your case
b. Whether we would be willing to represent you.

Obviously, the information you have sent us may not be sufficient to provide full answers to the above matters. If more information is needed, we will contact you to obtain the necessary additional information before we give you our evaluation of your potential claim.

We will try to be in touch with you by mail, telephone, or e-mail within a short time. We are an active law firm with many trials, however, and on occasion the requirements of providing service to our clients may cause us to delay answering you inquiry. If you do not hear from us in a reasonable time, don't hesitate to call. Under most circumstances, you should expect to hear from us within two days of our receipt of your inquiry.

OUR FEES: We charge no fee to provide the limited service described above. If you decide to employ our firm to represent you, we will provide contracts for you to read and sign. We also suggest you read the "Statement of Clients Rights" available from the FAQ Page. If we represent you we are willing to do so on a "Contingent Fee" basis, that is, you will owe us no fee for our services unless we make a recovery for you, and in the event of a recovery, your fee will be a percentage of the amount recovered, as outlined in the written contract we will provide to you.

LIMITATIONS ON OUR SERVICE:

1. The advice we provide is obviously limited by the information you provide to us. Final advice would be based upon a complete evaluation of your entire case. This cannot be accomplished with the limited information you have given us above. Often a full evaluation of a claim cannot be given without collecting considerable information, records, and other investigation. Often a decision about a claim can only be made after a personal interview.

2. Your claim may be barred by the Statutes of Limitations. These statutes provide that if a suit is not brought within a certain amount of time, the claim can never be thereafter brought. Likewise, the information you furnish may be furnished at a time so close to expiration of the statute of limitations that we do not have time to provide any help to you before the time expires. By asking for our help, you agree that we are not liable for failing to file suit on your behalf or failing to take any other action on your behalf.

3. You are not obligated to employ this firm by sending this information. Likewise, we are not obligated to accept you as a client by providing this help to you. We reserve the right to decline to represent you for any reason whatsoever. Once we have provided the limited service mentioned above, we reserve the right to refuse to become involved in further evaluation of your claim or in providing further advice. If we decline to represent you, or to provide additional advice, we will so advice you in writing at the address you have given us.

ADDITIONAL SERVICES: We are available to provide additional advice and services upon written or telephoned request unless we advice you of our decision not to do so as outlined above. Our firm does, however, generally limit its representation to claimants in personal injury, medical and professional negligence, products liability, and wrongful death matters as well as to certain other types or litigation on behalf of individuals (generally not corporations or insurance companies). Please feel free to write us at our Bayshore Office if more information is needed. It always helps to send along as much information as you have to help us help you.