Wilkes Law, PC
30700 Russell Ranch Road, Suite 250
Westlake Village, CA 91362
(747) 220-6606
Pre-Consult Questionnaire
Thank you for reaching out to Wilkes Law, PC. This form helps us gather key information to evaluate your potential personal injury matter.
Please note:
Submitting this form does not create an attorney-client relationship. We will carefully review your information and then contact you to discuss how we may be able to help.
Privacy Policy
All information submitted through this form is treated as strictly confidential. Wilkes Law, PC uses industry-standard 256-bit SSL encryption to protect your data. Sensitive information such as your Social Security number or driver's license will only be used if you formally retain our firm, and only when necessary for your case. Courts may require this information for identification or filings. If you have any questions about privacy or data use, please contact us directly.
Your Information
Contact information
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Primary
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Home
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Primary
Default number false
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Pronouns Used
Select an option
She/Her
He/Him
They/Them
Social Security Number
Driver's License Number
Are you married?
Yes
Spouse or Partner's Full Name
No
Do you have any military service?
Yes
Dates of Service
Branch of Military
Any Military Service Related Injuries
Rank Upon Discharge
Characterization of Discharge
No
Accident Information
Is this an auto accident?
Yes
Were you a driver, passenger or pedestrian?
What is the driver's full name?
No
What type of accident?
Date of Incident
Time of Incident
Indicate if AM or PM
City of Incident
County of Incident
Road/Intersection
if applicable
Were the police called to the scene?
Yes
Police Details
(Police Department Name, Officer's Name, Other Details)
No
Was an accident or incident report filed?
Yes
Report Number
Report Details
No
Unknown
Describe how the incident happened.
Please be as specific as possible.
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Other Party
If KNOWN / APPLICABLE
Name of Other Party
Other Party's Address
Other Party's Phone Number
Other Party's Job / Occupation
Other Party's Age
Other Party's Insurance Company
Other Party's Insurance Adjuster
Other Party's Insurance Coverage
Describe the other party's behavior or demeanor.
Witnesses
IF APPLICABLE
Witness #1
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Telephone
What did this person witness?
Not Applicable
Witness #2
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Telephone
What did this person witness?
Not Applicable
Additional Witnesses or Information
Statements Made
Have you told any police officer, investigator, insurance adjuster or any other person about the accident?
Injuries
Please describe in detail any and all aches, complaints, discomforts, and disabilities you suffered as a result of the incident.
Did you go to the hospital?
Yes
Name of Hospital
No
Did you go by ambulance?
Yes
Name of Ambulance Service
No
Did they take x-rays?
Yes
No
Have you seen a doctor since the date of the accident, other than at the emergency room?
Yes
Please list all doctors
name, address and telephone number
No
Symptoms
Check symptoms you have noticed since the accident
select all that apply
Ears ringing
Shortness of breath
Buzzing in ears
Dizziness
Problems sleeping
Head seems too heavy
Back pain
Loss of smell
Cold sweats
Loss of memory
Tension
Headache
Chest pain
Neck stiffness and pain
Upset stomach
Fainting
Increased sensitivity to light
Fatigue
Depression
Loss of balance
Hands cold
Feet cold
Nervousness
Pins & needles in legs
Pins & needles in arms
Numbness in toes
Numbness in fingers
Injury History
Have you had any accident-related injuries before this accident?
Past Injury #1
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injury Treated by
Not Applicable
Past Injury #2
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injury Treated by
Not Applicable
Past Injury #3
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injury Treated by
Not Applicable
Past Injury #4
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injury Treated by
Not Applicable
Additional Past Injury Information
Loss of Earnings
If you anticipate loss of earnings due to accident related injuries, please complete the following:
Employer
Your Position or Title
How are you paid?
Hourly
Gross Hourly Rate
Net Hourly Rate
Hours many hours per week?
Salary
Gross Amount
Net Amount
How many hours do you normally work per week?
Were you working at the time of the accident?
Yes
No
Additional Information
Any additional Information you think would be helpful?
Supporting Documents
Please upload or email any documents that would be helpful for the case such as:
Medical Records
Medical Bills
Insurance Correspondence
Accident Reports
Police Report
Would you like to attach the above documents now?
Yes - Attach Now
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Final Review & Submit
Thank you for completing this questionnaire. Your responses will help us evaluate your potential case. We will review your submission and contact you shortly to discuss how we may assist.
Please click the
SUBMIT
button below when you have finished answering all questions.