Personal Injury Law ROI

Claimant’s Details

You (the referrer) will receive a copy of this form on submission.

Forename(Required)

Surname(Required)

Date Of Birth(Required)

Address(Required)

Street Address Address Line 2 City County Postcode/Eircode

Next of Kin & Relationship To Claimant (If A Minor)

We require your clients email and mobile number for appointment reminders and arranging video consultation. We will also use this to contact your client in the event they experience any technical difficulties.

Email(Required)

Contact Number. Please include area code(Required)

Solicitor’s Details

Practice Name(Required)

Forename(Required)

Surname(Required)

Email(Required)

Contact Number. Please include area code(Required)

Solicitor’s Name (If Different From Above)

Forename

Surname

Reference Number For Your Client

Details Of The Index Event

Nature Of Injury? It is important you inform us if there was loss of life or catastrophic injury suffered(Required)

Date Of Injury(Required)

Please Indicate If You Intend To Share Relevant Notes/Records Or Reports

Any Other Relevant Information