September 10, 2010
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Welding Rod Intake Form

We look forward to answering any questions or concerns you have regarding welding rod injuries. All messages and personal information will be kept strictly confidential. Please fill out as much of this form as possible, and one of our attorneys will follow up with you shortly!

Name:


Address (City, State, Zip):


E-mail:


Day Phone:


Evening Phone:


Are you a welder?
Yes
No

What type(s) of welding has been performed? (i.e. MIG, TIG, stick welding, etc.)


Who manufactured the welding equipment or consumable that you used?


Work around fumes?
Yes
No

How long have you been exposed to fumes? (Hours per day exposed to fumes)


Last date of exposure:


State where exposure took place:


Diagnosed with Parkinson's or Manganism?
Parkinson's
Manganism
Neither

If so, when were you diagnosed and by whom?


Do you suffer from any of the following? (Please check all that apply)
Hands shake
Legs shake
Tremors
Faceless expressive
Loss of balance
Difficulty walking
Slowed movement
Problems sleeping
Slow/slurred speech
Rigid/tense muscles
Irregular writing
Poor memory
Muscle pain
Muscle weakness

Any other information that you feel may be relevant in our evaluating your potential claim:

First Name: Last Name:
Phone:
-

Sending this message does not create an attorney-client relationship, which can be done only after personal consultation and with a written retainer agreement.
Office Locations
Jersey City

660 Newark Avenue
Jersey City, NJ 07306
Phone: (201) 656-8500
Toll: 1-(866)-333-3529
info@bagoliefriedman.com
Clifton Offices

790 Bloomfield Avenue
Clifton, NJ 07012
Phone: (973) 546-5414

157 Ackerman Avenue
Clifton, NJ 07011
Phone: (973) 546-5414
Florida Office

3900 Hollywood Blvd.
Hollywood, FL 33021
Phone: (954) 966-2322
Fax: (954) 927-0337
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Personal Injury Attorneys serving clients in the State of New Jersey. All Rights Reserved.
 

Disclaimer: The New Jersey personal injury, wrongful death, worker's compensation, medical malpractice, nursing home abuse, product liability, environmental litigation, social security law, railroad / FELA, firefighter hearing loss, Asbestos / Mesothelioma, Lead Paint Poisoning and/or other legal information offered herein by Bagolie Friedman, LLC - Jersey City and Clifton New Jersey and Hollywood Florida Personal Injury Attorneys is not formal legal advice nor the formation of an attorney client relationship. Our law firm is licensed to practice law in New Jersey, New York and Florida. Nationwide and international coverage through associated counsel.