Consultation Form

 

   

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For immediate assistance seven days a week, call (714) 961-1966.

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For general inquiries, e-mail info@perezandperez.com or use our main Contact Form.


 
 

Free Consultation for Elder Abuse/Neglect

Use this simple form to provide us with information that will help us prepare for your free consultation. The information you are providing via this form shall be treated confidentially and is protected under the Attorney-Client privilege. Once received, we will phone you back at our earliest convenience.

Please note that this form is for elder abuse/neglect cases only. Use these links for other types of cases:
 
 
NOTE: * indicates a required field.
 
Personal Information
Name*
First Last
 
Date of Birth (mm/dd/yyyy)
Address
City, state, zip
Country
Phone*:  
(At least one phone number is required.
Use the format 555-555-5555.)
Home
Work ext.
Mobile 
Fax
E-mail
 
Case Information
Briefly explain what happened to the elder/dependent adult.*
Have you reported the incident to the local police, Ombudsman's office, or Department of Public Health/Social Services? Yes    No
 
Please provide the name of the agency contacted.
 
Describe the elder's/dependent adult's injuries.*
Where is the elder/dependent adult currently living?
Information about the nursing home or person(s) (name and address) you believe committed the abuse
 
Other Details
Please tell us how you found our web site. West / Findlaw Legal Directory (Lawoffice.com)
Martindale-Hubble Legal Directory
      (Lawyers.com)
Verizon Superpages Directory
      (SuperPages.com)
SBC Smartpages Directory (Smartpages.com)
Google Search Engine (Google.com)
AOL Search (AOL.com)
Yahoo! Search (Yahoo.com)
Other (please indicate):
   

Perez & Perez respects your privacy and does not sell or share your confidential information with any other parties. Read more about our privacy practices in our Privacy Policy.
 
The information provided at this web site by Perez & Perez, including all emails and newsletters, is not intended to be legal advice, and legal representation is subject to additional terms and conditions of a signed contract. To read more about this, please see our Legal Disclaimers.

 

 

1440 N. Harbor Blvd., Ste. 900, Fullerton, CA 92835, Phone: (714) 961-1966, Fax: (714) 961-1972

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