Clark Mason Attorneys | Little Rock, AR

The Mason Building - 216 Atkins Road
Little Rock, Arkansas 72211

(501) 219-0077 - (800) 516-2766

Contact Clark Mason Attorneys

Please contact us by telephone, e-mail or the client information form below.

Clark Mason Attorneys
The Prospect Building
1501 N. University, Suite 350
Little Rock, AR 72207

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Email:
inquiries@clarkmason.com

Telephone:
501-219-0077
800-516-2766

Fax:
501-219-2277

Client Information Form

The following form is to help you, as a potential client, tell us a little more about yourself and why you may need our assistance.Â You may not have enough information available to answer all of the questions. That is ok. Fill out as much of the form as you can and a staff member of Clark Mason Attorneys will contact you shortly. Please note that filling out the following form does not create an attorney/client relationship between you and Clark Mason Attorneys.

Name:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cellular Phone:

E-mail Address:

Name of the Injured Person:

Injured Person's Relationship to You:

Address of Injured Person if Not You:

Please Name All Immediate Family Members of the Injured, Birthdates and Occupations:

When Did the Injury Happen?

Where Did the Injury Take Place?

How Did the Injury Happen?

Did the Injured Person Receive Medical Treatment?

Yes
No

*Where did the Injured Person Receive Medical Treatment?

Was There a Police Report?

Yes
No

Did the Injured Person Die From Their Injuries?

Yes
No

* What was the Injured Person's Date of Death?

Was the Injured Person a Resident of a Nursing Home?

Yes
No

* Please List all Nursing Homes That the Injured Person Lived In and the Dates in Which They Lived At the Nursing Homes.