If you believe that you or someone close to you may have a Birth Injury related personal injury claim, please fill out the following questionnaire. By submitting the information below, you will enable the attorneys at Napoli Bern, LLP to evaluate your case based on its merits. Please be as complete as possible in the information you provide. If you would like to contact Napoli Bern, LLP for reasons other than a Birth Injury related personal injury claim, please email info@nblawfirm.com or call 1-888-LAW-IN-NY. There is no charge for this evaluation General Contact Information: Your Name: Street Address: City: State: Zip: E-mail Address: Phone Number: Work Number: Fax Number: What method would you prefer we use to contact you? E-mail Phone Fax What time of day would you like us to call? Morning Afternoon Evening N/A General Incident Information: What day did the birth injury occur (00/00/00)? / / In what city and state did the injury occur? Please briefly explain the incident that caused the injury: Please briefly describe the injuries: Do you believe that any of the injuries are permanent? Yes No Not Sure Important Legal Disclaimers: Yes No - I agree that this matter may be referred to an attorney in my area who may contact me. Yes No - I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. By Clicking the appropriate box below, I agree to: