Online Consultation Form

Please either call our office or complete the following for a free consultation. Our team meets every Monday morning to review all our new potential cases. If your needs are urgent, please call 945-8901 / 1-800-309-4445 and speak to one of our new accident intake specialists. (*) Denotes required information

Please provide the following contact information:

Name:*
Street Address:
City:*
Postal Code:
Phone:*	( xxx-xxx-xxxx )
Email:
Age:

Describe your Accident

When did the accident occur?

Who was at fault for the accident?

What are your injuries?

At the time of the accident were you working, a student, homemaker, retired, or on disability? Working Student Homemaker Retired Working

If working, have you returned to work? Yes No

If so, when?

Describe your work:

What is your annual income? $

Do you have a private medical or disability plan? Yes No

Have you applied for accident benefits? Yes No

Are you getting income replacement benefits, attendant care benefits or caregiver benefits? (Please give details)

Are you getting housekeeping assistance from your insurer? Yes No

Is your insurer paying for medical/rehabilitation benefits like prescriptions, physiotherapy, chiropractic, psychological, or massage? (Please give details)

Additional Comments:

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