Your Next Stepswith the Alvarez Law Firm

Tobacco injuries can come from cigarettes, e-cigarettes, secondhand smoke, smokeless tobacco, and more. What they have in common is that their injuries are life-changing and very expensive for the victims and their families. If you think you have a tobacco injury, personal injury or wrongful death case, do not hesitate to get in touch with our team at The Alvarez Law Firm to get your questions answered about the process and your case value, and much more. We are ready to get started on a winning case for you today. Call now!

Jurisdiction

Is the SOL verified?

Statute of Limitations (Verified)

Due

Done

Date of Intake

Person Performing Intake

Referral Source

Referred Form

Qualified?

Resolution

Case Details

Case Title

Caption Plaintiffs

Caption Defendants

Judge

Court

Case Number

Client History

Social Security

Smoker's Height and Weight

Date of Birth

Place of Birth

Is the smoker deceased?

Is/was the smoker married?

Does the smoker have an Ex-Spouse?

Does the smoker have children?

Father's Info: Name/Living/Sx Hx/SRD

Mother's Info: Name/Living/Sx Hx/SRD

Sibling's Info: Names/Living/Sx Hx/SRD/Location

Extended Family & Friends Info: (Sx Hx/SRD/Knowledge about Client)

Residency: Location & Dates

Schooling: Name/Location/Dates

Job History

Profession/Employer/Location/Dates

Military History

Criminal History?

Have they filed for bankruptcy?

Have they file lawsuits in the past?

Issues: (Fam/Drugs/EtoH)

Smoker's Lifestyle (Sports through Life, Daily Life before and after DX)

Smoking History

Exposure Type

Began Smoking Date

Began Smoking Age

Pack Year History

Brand History (Brand/Dates/Amount/Reason/Source)

Cigarette Purchase History

Tobacco Mailing List?

Tobacco Merchandise?

Med Docs Smoking Amount & Date

Quit Attempts (Method/Dates/Duration/Reason/Source)

Med Docs Smoking Amount & Date

Quit Smoking

Medical History

Alleged Diagnosis Date

Diagnosed Smoking Related Disease

Beginning of Symptoms for SRD

Dx Physician (Name/Method of Dx/ Sx Related per Dr?)

Procedures (Name of Surgery/Date of Procedure/Notes)

Insurance Name

Pharmacy Name

Prescriptions (Name/Date/Notes)

Sx Related Damages

Non-Smoking Related Medical Issues (DODx/Dr. Info/Procedures/Treatment)

Notes

Treaters/Insurance/Pharmacy

By completing this form, you are giving us permission to follow-up by phone, email or text.

This field is required.

Submit

Tobacco

Your Next Stepswith the Alvarez Law Firm

Let’s talk about your case.