First Name *
Last Name *
Address
City
 State
 		Zip Code
E-mail Address *
Day Phone
Night Phone
Cell Phone/Pager

Please provide personal background on the person needing assistance or who has been injured. Many times we are contacted by someone other than the person victimized, such as a child on behalf of an elderly parent, or a wife on behalf of a husband, etc.
The following information is for me:
Yes    No   
If No, my relationship to that person is:
Age
Deceased
Yes    No   
Date of Death
Living
Yes    No   
Date of Injury
Location of Patient
 For How Long?
City
 State
 		Zip Code
Last Nursing Home Resided
City
 State
 		Zip Code
Last Hospital Resided
City
 State
 		Zip Code

Why do you need help? Please provide a brief overview in 200 words or less describing what you feel has occurred. Please limit your brief statement to general facts of your case the damage or injury that has been suffered.

• State the date you first learned that you or your loved one had been damaged?
• What occurred?
• Where did it happen?
• City, State - Facility
• Who do you believe caused the harm?
• What damages were suffered?

Case Description
Have you made any complaint?
Yes    No   
When?
To whom did you complain?
How do you wish to be contacted?
How did you hear about us?
Yellow Pages    Internet   
Newspaper    Other   
Questions/Comments
When you have completed the information above, please press submit to send it to Law Office of Gia Kosmitis. Your information will be kept confidential with our office.

* Required to submit this form



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