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Injury Claim Intake Form

Contact Hartley Hampton, P.C., for a No-Cost Consultation about Your Injury Claim

The personal injury and wrongful death law firm of Hartley Hampton, P.C., provides quality legal representation and counsel for injured people throughout south Texas. Trial lawyer Hartley Hampton is board certified in Personal Injury Trial Law by the Texas Board of Legal Specialization and in Civil Trial Advocacy by the National Board of Trial Advocacy, and has also been selected by his peers for inclusion in the Best Lawyers in America (Copyright Woodward/White, Inc., of Aiken, S.C.) for years.

We invite you to contact Hartley to schedule a no-cost consultation about your medical malpractice claim, injury by a defective product, motor vehicle accident, or other injury claim.

Please take a moment to give us an overview of your situation by filling and submitting out this short questionnaire. We will respond to your message as soon as possible. Thank you.

NOTE: An asterisk (*) indicates REQUIRED information.

*Your Name:

Address:

City:

State:

Zip:

*E-mail address:

Phone Number:

How would you like to be contacted?
 Email
 Phone

*Name of injured person(s):

*Relationship of injured person(s) to you:

*Date of injury (mm/dd/yyyy):

*Name(s) of healthcare providers you believe contributed to injury:

*Description of injuries:

Did these injuries result in permanent disability?
Yes No

Description of permanent disabilities:

If the injury resulted in death, was an autopsy obtained?
Yes No

Have you contacted other attorneys?

Have you signed a contract with any other attorney?
Yes No

Send me a copy of this email.

The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk.

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  • Hartley Hampton
  • Toll Free: 866-635-0811
  • Phone: 713-574-8660
  • Fax: 713-650-6458
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Areas We Serve

The Houston, Texas, law firm of Hartley Hampton, P.C., serves businesses and individuals in communities throughout south Texas in areas such as Bellaire, Baytown, Pasadena, La Porte, Alvin, Pearland, Lake Jackson, Conroe, the Woodlands, Tomball, Kingwood, League City, Humble, Galveston, Clear Lake, Friendswood, Texas City, Katy, West Houston, Orange, Beaumont, Port Arthur, Sugar Land, Missouri City, Victoria, Corpus Christi, Austin, San Antonio, Texas Gulf Coast and Dallas.

Harris County • Galveston County • Brazoria County • Matagorda County • Fort Bend County • Waller County • Grimes County • Walker County • Montgomery County • Liberty County • Chambers County • Jefferson County • Orange County

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