24801 Pico Canyon Road, Suite 100
Stevenson Ranch, CA 91381
Tel: (661) 310-1363 | Fax: (661) 310-1480
Thank you so much for trusting Miller Wilmers, APC to review your personal injury matter. We understand this can be a confusing and traumatic time in your life and strive to provide you with peace of mind and clarity going forward. In order to best serve you, we ask that you answer the below questions as accurately and truthfully as possible. 

Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. Most courts require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:
  • initial service
  • in court orders
  • in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact information

Emails
*
Upon submission, a copy of this form will be sent to the primary email.
Addresses
Phone numbers

Please answer the following questions in detail regarding the accident you were involved in. 

Name of restaurant, store, or other establishment - include specific location of premises (i.e. walkway, lobby, bathroom, etc.)

I.e. were you a customer, worker, attendee, etc.?

Be as specific as possible including your body movements when you fell and/or were injured.

I.e. water/liquid, raised/cracked floor, etc.

I.e. was their surrounding stains from a spill that had dried, had you seen/reported the spill before the accident, etc.

I.e. sneakers, dress shoes, high heels, etc.

Please answer the following questions in detail regarding the injuries and/or body parts affected as a result of the accident you were involved in. 

Please describe the frequency and areas in which the chronic condition causes you pain.

Please answer the following questions in detail regarding the medical treatment you have received as a result of the accident you were involved in. 

Include healthcare facility, address, telephone number and doctor's name.

I.e. doctor's office, chiropractor, physical therapist, etc.

Please answer the following questions regarding your health insurance status. 

If you are covered under Medi-Cal or Medicare, please enter your Medi-Cal/Medicare No.

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

DISCLAIMER: The submission of information does not establish an attorney-client relationship. This form is for case evaluation purposes only. Our office will contact you after review to further discuss hiring/retaining Miller Wilmers, APC for your legal matter. Thank you.