De Caro & Kaplen, LLP
20 Vesey Street • New York, New York 10007
Toll Free: 1 866-BrainLaw • (212) 732-2262 • FAX (212) 732-3905
mvk.brainlaw@verizon.net

To contact us regarding a potential case, kindly complete and submit the form below. Someone will get back to you shortly. Please make sure to read the "TERMS" at the bottom of the form prior to submitting your information.

First Name*
Last Name*
Email*
Phone*
City
State
When is the best time of the day/evening to reach you by phone?
What type of accident/loss have you suffered?
Medical Malpractice
Legal Malpractice
Construction Accident
Landlord Negligence		 Vehicle Accident
Burn Injury
Slip and Fall
Other (describe below)
How did you hear about us?
Referred by family/friend
Referred by another attorney
Other		 Yellow pages
Direct mail
Search engine
Please briefly describe in your own words the facts of your potential case

TERMS: I agree that submission of this form does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this form. I understand that an attorney-client relationship with our firm can only be formed by entering into a written fee agreement with our firm after we have thoroughly reviewed the facts of your potential case.