Animal Law Intake Form

Telfer Law
331 J Street, Suite 200
Sacramento, CA 95814
(916)446-1916
(916)446-1726 –facsimile

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 Jason Chau for assistance.

Telfer Law Animal Law Intake Form

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Name*
First Last
Previous Names/Aliases
Date of Birth*
Phone*
Additional Phone
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
Marital Status*
Spouse Name
First Last
Date of Birth
How did you hear about our office?*
Do you currently have any hearings or appearances that require attendance?*
When?*
Please describe the nature of the hearing and/or appearance:*
Are there any important circumstances that you think require immediate attention?*
If so, please explain:*

INFORMATION CONCERNING YOUR ANIMAL
Name of YOUR Animal*
Age*
(Approximate)
Breed (if known)*
Current Location of Animal(s):*
Current Health of Animal(s):*
Has your animal received training of any kind?*
Please explain:*
Where / When?
Has any animal you own or previously owned been involved in a bite incident(s)?*
Please explain:*
INFORMATION CONCERNING OTHER ANIMAL(S)
Was another animal involved?*
Animal Name*
Owner Name*
First Last
Owner's Phone Number*
Breed of other animal:*
Current health of other animal:*
Current location of other animal (if known):*
Were any other animals involved?*
Please provide name, breed, age of animal(s) as well as their current health and location:*

INFORMATION CONCERNING THE INCIDENT
Date of Incident*
Time

: HH

MM
Address*
Please identify the location that the incident took place at:

Street Address Address Line 2 City State ZIP Code
Describe in detail how this accident happened:
Did you take any photos at the incident?*
Are you aware if any other individual took photos?*
Name:*
Were there any witnesses?
Who?*
Name Phone Number Email Address
Information Witness(es) know:*
Did the police arrive at the location of the incident?*
What Police Department?*
Is there a police report number (can be found on accident exchange form)?*
Report Number:*
Was there a "dangerous dog" designation of any sort?
Please explain:*
Was Animal Control called?
Results of Animal Control:*
Was any other report taken?*
Have you been contacted by the City of County in which you reside concerning your animal?
Please explain:*
Have you been cited?*
Amount:*
Have you paid any citation(s)?*
Please provide status of fine (paid, pending, etc.):*
Did this incident occur on private property?*
How would you describe the property where this accident occurred?*
Do you know the name of the homeowner/tenants/business owner on the property where this occurred?*
If yes, 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?
Insurance Company Name*
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did you report this accident to any insurance agent or company?*
Did you give a statement to any insurance company?
If yes, when and what insurance company?*
Claim Information
Insurance Company Claim Number

INJURIES & TREATMENT - ANIMAL
Were any animals injured?*
Animal Name*
Injuries Sustained:*
Treatment Received:
What is the approximate amount of the veterinary bill(s), if known?*
Have the veterinary bills been paid?*
Amount left to be paid:*
Please enter a value greater than or equal to 0.
Did you take any photographs of any injuries?*
Has the animal had any other injuries or medical treatment before this accident?*
Are the injuries/medical treatment within the past five years?*
If yes, please list year of previous accident, type of accident and type of injuries/medical treatment:*
Was the animal prescribed any medication concerning the accident?*
If yes, what medication?*
Has the animal had any other injuries after this accident?*
If yes, please describe:
ANIMAL INJURY RELATED DOCUMENT(S)
Drop files here or
INJURIES AND TREATMENT - PERSON(S)
Did any person sustain injuries from incident?*
Name*
First Last
Phone*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Injuries sustained:*
Did anyone have to go to the hospital due to the injuries?
Who?
What is the approximate amount of their medical bills, if known?*
Have the medical bills been paid?*
Did you take any photographs of any injuries?*
Number
Were you taking any medication on the date of the accident?
Please explain:
INJURY RELATED DOCUMENT(S)
Drop files here or
LOST INCOME OR WAGES
Did you miss work time as a result of this accident?*
Your employer/occupation:
Employment
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.
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?*
Who? What is their current involvement in the case?
Please provide any additional important information concerning your case below:
Have you or are you filing for bankruptcy?*
If yes within the past 10 years, please explain:
EMERGENCY CONTACT NAME
First Last
EMERGENCY CONTACT NUMBER
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.*
- AGREE

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.

Telfer Law Animal Law Intake Form

Step 1 of 5

INFORMATION CONCERNING YOUR ANIMAL

INFORMATION CONCERNING OTHER ANIMAL(S)

INFORMATION CONCERNING THE INCIDENT

INJURIES & TREATMENT - ANIMAL

INJURIES AND TREATMENT - PERSON(S)

LOST INCOME OR WAGES

ADDITIONAL INFORMATION