Injury Institute
Health Centers of California

Call : (877) 878-0470
Fax :  (310) 943-1752

Please fill out the following Case Evaluation form and provide as much information as possible.  All informations are kept strictly confidential and are used only by our experts for the evaluation of your case to help you get the legal and medical assistance you require.

CONTACT INFORMATION

Your Name :
Street Address :
City :
State :
Zip Code :
Phone :
Email Address :

INJURY INFORMATION

Date of Injury :
Injury Type :	Auto Accident Slip and Fall Work Injury Other
Describe What Happened :
Describe Your Injuries:
Other Comments :
Please copy the 5 characters