Confidential Free Consultation Form

Chad Davis and his team at the Chad Davis Law are personal injury law specialists.

Please Complete Our Confidential Questionaire to Book Your Free Consultation with Chad Davis

I will personally make sure you are satisfied throughout the entire process.

Allow me to guide you through the legal intricacies, ensuring you receive the compensation you rightfully deserve. Your well-being is our priority, and we are committed to relentlessly pursuing justice on your behalf.

For professional service from a local Texan resident.

Your Name *

First

Last

Date of Loss? When did the injury happen? *

Phone Number *

Email *

Address

City/State ZIp

Date of Birth. What date is your Birthday? *

Social Security Number

Drivers License Number

Referred By. How did you find us?

Secondary Contact Person

Ie Name, relationship, phone, email, address

Detailed Description of the Injury

Describe how the injury occurred

Location/Time/Condition/Surroundings

Important information regarding the scene of the injury

Police Report

Police Report was Created and is Favorable
Police Report was Created and is UnfavorableSecond Choice
ThiNo Police Report was Createdd Choice

Pictures

I have pictures
I do not have pictures

Witness Information

Responsible Party Information

Contact info for the person who caused your injury

Responsible Party's Insurance

Insurance Info for the person who caused your injury

First Party Insurance

Your own insurance information

Detailed Description of your Injuries

Tell me what hurts or what your diagnosis was

Lost Wages

I have lost wages due to my injury
I don't have lost wages due to my injury

All Medical Providers Seen for Injury

Any doctor or medical provider that you saw so far (include hospitals/emergency services)

Health Insurance Information

What health insurance do you have?

Personal Care Physician/Prior Claims/Unrelated Medical History

Please describe your medical condition prior and unrelated to the subject injury. Please include whether any unrelated condition was aggravated by the subject injury.

Any other information you want to include about you or your claimMedical History (copy)

Please feel free to write down anything else that you feel I should know about you or our claim so I can try to help you better

Chad Davis Law. Personal Injury Lawyer in Dallas.