Personal Injury Intake Form
Please fill out this form to the best of your ability. This information is kept private and confidential, and will be used only to facilitate our representation of your case.
Please contact our office at 503-274-4757, or via email at:
if you have any questions or concerns.
O'Reilly Law Office team.
What is the best way to get in contact with you? Please enter your phone number, email, or both.
What was the date/time that the accident occurred?
Describe the accident with in as much detail as you can remember. Please include any details that you think might be important. (Try to include some of the following: Where were you going? Who else was in the car? Did the airbags deploy? etc.)
Please tell us about your injuries.
Did the police come to the scene, and was there a police report?
Yes, the police arrived at the scene.
No, the police did not arrive at the scene.
Yes, there was a police report.
No, there was no police report.
Did the accident occur in Oregon or Washington?
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