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This web site is sponsored by the law offices of Brayton Purcell LLP to introduce our firm, and our attorneys, and to provide information on legal, legislative, asbestos, mesothelioma and other medical topics. We represent clients in all 50 states and have offices located in:

California
222 Rush Landing
Novato, CA 94945
Oregon
111 SW Columbia, Suite 250
Portland, OR 97201
Utah
215 South St. Str., Suite 900
Salt Lake City, UT 84111

Please read our disclaimer and privacy policy.

Your Name or Law Firm:
Phone Number:
E–mail Address: (Privacy Policy)
Best Time to Contact/ Method to Contact:
Name of Injured Party:
Date of Birth or Age of Injured Party:
Type of Case:	If Other:
Is this a wrongful death case? Yes No If “yes,” please provide the date of death of decedent.
Diagnosis or Injury: If injured party was diagnosed, when and how if known: If not an asbestos or other type of toxic exposure case, when and how did the injury occur if known. (If it is an asbestos or other type of toxic exposure case, please fill out No. 4 Exposure Summary below.)
Smoking history if applicable:
If an asbestos case or other type of toxic exposure, please give a brief exposure summary:
Is the injured party married? Yes No Dose the injured party have dependents? Yes No
If this is a work–related injury, are you referring the injured party’s workers’ compensation case? Yes No
If this is an asbestos case, is your office filing any of the bankruptcy or administrative claims? Yes No If “yes”, which one(s)?
Did the injured party sign a fee contract with your firm? Yes No If so, please forward upon acceptance of the case.
Please confirm that we have permission to contact the injured party. Yes No If yes please provide contact information:
Contact Person’s Name:
Address:
City:
State:
Postal Code:
Phone Number:
E–mail Address: (Privacy Policy)
Other Comments:

Attorney Referral Form

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Attorney Referral Form