Birmingham Nursing Home Abuse Case Submission Form

For a free, no-obligation consultation with an experienced Birmingham nursing home abuse attorney regarding your claim, please submit the following response form. We will respect the confidentiality of your information to the fullest extent. Form submissions are relayed to us through our highly secure servers.

Tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be communicated with anyone. It is necessary only for purposes of enabling us to do a conflict of interest check prior to responding to you. We cannot respond without being able to do our conflict check. Email Field is required.

First Name

Last Name

Number, Street & Apt.

City

State

Zip

Email

Day Phone

Night Phone

Please provide a brief personal background of the person needing assistance. Many times we are contacted by someone other than the person in need of help, such as a parent on behalf of a child, or wife on behalf of a husband. Please provide the following information on behalf of the person who needs assistance.

The following information is for myself: Yes No

If "No" my relationship to the following person is:

First Name

Last Name

Age

Occupation

For how long

Current or last employed

City and State where last employed

Highest grade completed

Schools/College attended

Degrees

Year degree granted

Special training or experience in

Why do you need help? Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request. You can provide more detailed information below, but for now please confine yourself to providing us with a brief statement of the general facts of your case, injury and damages.

State the date you were injured or when you first learned that you had been injured?

What occurred?

Where did it happen? Please type in the City, County and State where it happened:
City
State
County

Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:

What damages were suffered? Describe the damage you have suffered:

Has anyone already filed a suit? Yes No

When is the best time to reach you by telephone?

When the information you have provided is complete, please press the Submit button below to send it to us. Your information will be kept strictly confidential.

The Walker Law Firm is committed to upholding the quality of care in our long-term care institutions by taking swift legal action to compensate Birmingham nursing home residents and their families for injuries resulting from neglect or inadequate care. Only this way will the quality of care for all Birmingham nursing home residents be assured. If you feel that you or a loved one has been victimized by abuse or neglect while in the care of a senior citizen facility, call the Birmingham nursing home lawyers at Walker Law Firm now at (877) 925-5373 or fill out our FREE CASE EVALUATION FORM. The initial consultation with a Birmingham nursing home injury attorney is free of charge, and if we agree to accept your case, we will work on a contingent fee basis, which means our Birmingham nursing home attorneys get paid for our services only if there is a monetary award or recovery of funds. Don't delay! You may have a valid claim and be entitled to compensate for your injuries, but a Birmingham nursing home abuse lawsuit must be filed before the statute of limitations expires.

The above is not legal advice. That can only come from a qualified attorney who is familiar with all the facts and circumstances of a particular, specific case and the relevant law. See Terms of Use.