Consultation Form



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

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Free Consultation for Personal Injury

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 personal injury cases only. Use these links for other types of cases:
NOTE: * indicates a required field.
Personal Information
First Last
Date of Birth (mm/dd/yyyy)
City, state, zip
(At least one phone number is required.
Use the format 555-555-5555.)
Work ext.
Case Information
Briefly explain how the accident happened.*
Do you have auto insurance? Yes    No
Please provide the name of your insurance company and your policy or claim number.
Describe your injuries.*
Which doctors have you seen?
Information about the other driver (name, address, driver's license,
insurance information)
Was a police report written for the accident?   Yes    No

If yes, please provide the following information.
Police Department
Name City
Police Report Number 
Date of the Accident
Location of the Accident
Describe the damage to your vehicle and the damage to the other vehicle. Amount or estimates of damage costs?
Other Details
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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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