George C. Creal, Jr. P.C.

Call Now For A Case Evaluation

(770) 961-5511

George C. Creal, Jr. P.C.

Motor Vehicle Collision/Injury Questionnaire

Thank you for asking this firm for assistance in your auto accident claim. In order to begin processing your claim, we need to develop the basic information of the events of your collision. All information that you provide is confidential and protected by attorney-client privilege. It is important to be accurate and complete – incorrect or missing information could seriously affect your case in a negative manner! Please fill this form ASAP, keeping a copy for yourself. Please refer to it from time to time. If more or different information is appropriate, please provide this to me.

Information About You


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Emergency Contact

Employer Information

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Medical Information

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Pharmacy Information

Prior Accidents Or Injury


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Insurance Information - Other Driver

Insurance Information - Your Auto Insurance

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No

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Your Health Insurance Information

Prior Medical Providers and Hospitalizations:

Confidentiality Note: The information contained in this questionnaire is legally privileged and confidential information intended only for the use of the individual or entity named above. If the reader of the message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of the message is strictly prohibited.