Potential Case Submission
Call me at 206-488-9336 or complete this form for me to evaluate your case.
Your Name
Name of patient (if different)
Patient Age
Your Relationship to patient
Address (Street, City, State, Zip)
Daytime Phone
Cell Phone
Email
Date of incident giving rise to claim
Do you have copies of your medical records? If no, which records do you have?
How were you referred to Riley Law Firm?
Description of Claim
Have you consulted with any other lawyers regarding this claim? If so, please identify the lawyer(s) and state whether you have an agreement of representation with the lawyer(s).
Has this matter previously been in litigation or arbitration? If so, please describe when and where and the current status of the matter.
Has this matter previously been in litigation or arbitration? If so, please describe when and where and the current status of the matter.
1. You do not have a lawyer-client relationship with Riley Law Firm, and are not creating such a relationship by the submission of this form.
2. No lawyer-client relationship will arise between Riley Law Firm, or any of its lawyers, and you until and unless a written representation agreement has been signed by both parties.
3. Your submission of this information to Riley Law Firm was not solicited by Riley Law Firm, but rather was initiated by you after reading about Riley Law Firm on its website.
4. You do not have a retained lawyer in connection with this matter, except as may be specifically disclosed above.
I agree to the above.
Note, before submitting this form, please enter the code you see displayed below.
Lawsuit Form
Please fill out the form as completely as possible. The more info we have, the more quickly we can help you.
Once we finish going over the details of your case, we will contact you.
