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Personal Injury Enquiry Form

Please fill out the relevant information in the form below and we will get back to you as soon as possible.

Personal Details

1. Your Name*

Are you enquiring on behalf of someone else?

If yes, answer question 2.

If no, go to question 3.

2. Their name and your relationship to them

3. Your (or their if answering for someone else) Date of Birth

4. Date of Injury*

5. Accident Location*

6. Date of death (if applicable)

7. Your (or their, if enquiring for someone else) address*

8. Phone Number*

9. Email Address*

10. Preferred means of contact ?
EmailPhonePost

11. Have you been a client of Ashtons Legal before?
YesNo

12. If so have you provided ID?
YesNo

Details of Event / Incident / Accident that caused the injury

Brief Detail of the Circumstances*

Details of injury*

Is your injury still being treated and/or causing you difficulty? If so, please give brief details:*

Did you visit Hospital/GP?

If yes - which hospital(s)?

How long were you in hospital/what action was taken?

If GP, what did they advise/prescribe?

Name of the person or organisation who you think is at least partly responsible for your injury*

Their address

Details of financial losses

If you usually work, how much have you lost if your injury has prevented you from working?*

Have you needed any care? If so, how much has it cost?*

Have any other expenses been incurred as the result of the injury (eg public transport if you were unable to drive)?*

Is injury still affecting your daily life? How?*

Have you already consulted any other lawyer about this injury claim?

How did you hear about us?*

I accept that my data will be held for the purpose of my enquiry in accordance with Ashtons
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