Free Injury Case Evaluation Form

This form is provided by Dwyer, Dykes & Thurston, L.C. for a FREE, NO OBLIGATION evaluation of your Kansas or Missouri injury claim. Please fill in each of the form fields below to supply us with the information needed to complete the evaluation.

The information you submit will be kept confidential once it is received by us, and you will receive a response by email with our evaluation. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: tomt@kansaslaw.net or fax it to us 24 hours a day at (913) 383-2662.

Biographic information:
(Tell us a little about yourself)

First Name
Middle Name
Last Name

Street Address 1
Street Address 2

City
State
Zip Code

Home Telephone Number (xxx-xxx-xxxx)
Email Address

Case Information
(Tell us a little about the case you would like evaluated)

Do you have an attorney representing you for this accident claim?       Yes     No

What date were you injured?
Where were you injured (city, county, state, country)?

Please describe how the accident happened?
Accident Facts:

What type of accident did you have?
(Multiple items may be chosen)
Motor Vehicle
Work Related
Product Injury
Pedestrian
Slip and Fall
Premises
Other

Are you still receiving medical treatment for your injuries or have a medical appointment scheduled?

                   Yes
                   No

Describe your injuries from the accident:

NOTICE:

Your responses will be sent over a non-secured link. It may be possible for someone not intended to view your responses. If you are concerned about privacy, please feel free to contact us by telephone at (913) 383-3131 to discuss your situation.
You are under no obligation once you submit this information, and it will be kept confidential when received by our office. This is a FREE service.

Biographic information: (Tell us a little about yourself)
First Name	Middle Name		Last Name
Street Address 1		Street Address 2
City	State		Zip Code
Home Telephone Number (xxx-xxx-xxxx)		Email Address
Case Information (Tell us a little about the case you would like evaluated)
Do you have an attorney representing you for this accident claim? Yes No
What date were you injured?		Where were you injured (city, county, state, country)?
Please describe how the accident happened? Accident Facts:
What type of accident did you have? (Multiple items may be chosen) Motor Vehicle Work Related Product Injury Pedestrian Slip and Fall Premises Other		Are you still receiving medical treatment for your injuries or have a medical appointment scheduled? Yes No
Describe your injuries from the accident:
NOTICE:
Your responses will be sent over a non-secured link. It may be possible for someone not intended to view your responses. If you are concerned about privacy, please feel free to contact us by telephone at (913) 383-3131 to discuss your situation. You are under no obligation once you submit this information, and it will be kept confidential when received by our office. This is a FREE service.