Animal Law Intake Form

TELFER LAW

980 9th Street, Suite 2550
Sacramento, CA 95814

(916)446-1916

The Firm is located on the twenty fifth floor of Park Tower.

*Street parking near Cesar Chavez Park as well as two parking structures nearby.

If you are seeking information concerning potential representation, please fill out the form below with as much detail as possible. Please highlight time sensitive matters in your claims, if any. If you have any documents that you wish to submit to our office, you will have the opportunity to submit at the end of the form. Due to our limited staff and current schedule, we ask that you provide as much information as possible to evaluate your case. All cases are considered time sensitive and therefore, you should continue to search for representation. Should you have any additional documents you wish to submit to our office that exceed the size capacity, please contact Lia Unanyan for assistance.

Animal Law Intake Form

First name

Last name

Phone

Alternate Phone

Address

Birthday

Do you currently have any hearings or appearances that require attendance? If yes, please list date/time/nature of appearance or hearing:

Please explain:

Name, Age, Breed of Your Animal

Current Location/Health of Animal(s)

Has your animal received training of any kind? If yes, please explain:

Please Explain:

INFORMATION CONCERNING OTHER ANIMAL(S)

Animal Name

Owner Name

Owner's Phone Number

Breed of Other Animal

Current Health and Location of other Animal (if known)

Please provide name, breed, age of animal(s) as well as their current health and location:

INFORMATION CONCERNING THE INCIDENT

Date of Incident

Time of Incident

Address

Describe in detail how this accident happened

Name

Phone Number

Information Witness(es) know:

What Police Department? Please provide Report Number:

Please Explain:

Was Animal Control Called? If yes, please explain results:

Please Explain:

Amount/Status of Fine Payment:

Please list all residents, occupants, and/or owner(s):

Do you know the name of the insurance carrier of the owners/tenants where this accident occurred? If yes, please state insurance carrier:

Did you give a statement to any insurance comany? If yes, when/what insurance company?

INJURIES & TREATMENT - ANIMAL

Were any animals injured? If yes, please provide: Animal's Name, Injuries Sustained, Treatment Received, Approximate Amount of Veterinary Bills, Status of Payment, Amount Left to be Paid:

Has the animal had any other injuries or medical treatment before this accident? If yes, are the injuries/medical treatment within the past five years? Please list any prescribed medications from the accident:

Has the animal had any other injuries after this accident? If yes, please explain:

INJURY RELATED DOCUMENTS

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INJURIES & TREATMENT - PERSON(S)

Did any person sustain injuries from incident? If yes, please list: Name, Phone Number, Address, email and description of injury:

Did anyone have to go to the hospital due to the injuries? If yes, please list amount of hospital bills and status of payment:

Were you taking any medication at the time of the accident? If yes, please explain:

INJURY RELATED DOCUMENTS

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Employer/Occupation Type (Full-Time/Part-Time):

Please identify date(s) and hour(s) missed from work:

ADDITIONAL INFORMATION

PLEASE UPLOAD RELEVANT DOCUMENTS HERE. Should you have any additional documents you wish to submit to our office that exceed the size capacity, please contact Jason Chau for assistance.

Upload File

Any and all information collected within this form will be used exclusively by Telfer Law for the purpose of contacting you about your potential case. We do not share, sell, or otherwise disseminate any personal information we collect with third parties.

Do you currently or have you had another attorney in this matter? If yes, please list name and current involvement in case:

Please provide any additional important information concerning your case below:

Have you or are you filing bankruptcy? If yes, within the last ten years, please explain:

Emergency Contact Name

Emergency Contact Phone

I understand that this is a free consultation about my accident and that I am not represented until I speak with the attorney who agrees to accept my case and I sign a fee agreement. I understand that my case may or may not be accepted by the attorney.

Any and all information collected within this form will be used exclusively by Telfer Law for the purpose of contacting you about your potential case. We do not share, sell, or otherwise disseminate any personal information we collect with third parties.

The Firm expressly prohibits discrimination, harassment and retaliation based on race, color, sex, religion, creed, national origin, disability, genetic information, age, martial status, sexual orientation, pregnancy, political view or affiliation, veterans’ status, or any other protected category.