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Brain Injuries Information Center

Brain Injuries Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

Business Phone

Cellular or Pager

Cause of the injury:
Car accident
Work-related accident
Sports or recreational accident
Possible medical malpractice
Assault
Other

Symptom(s) that have been experienced:
None
Headaches
Dizziness
Vertigo
Loss of sleep
Memory loss
Difficulty with numbers
Sensitivity to light
Depression
Personality change

Diagnostic tools that medical professionals have used to determine the extent of the injury:
None
MRI
CT Scan
PET Scan
EEG
Other(s):

Has occupational or physical therapy been utilized?
Yes
No
Not Sure

Any other information or concerns?

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  • 1150 Bissonnet
  • Houston, Texas 77005
  • Hartley Hampton
  • Toll Free: 866-635-0811
  • Phone: 713-574-8660
  • Fax: 713-650-6458
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Areas We Serve

The Houston, Texas, law firm of Hartley Hampton, P.C., serves businesses and individuals in communities throughout south Texas in areas such as Bellaire, Baytown, Pasadena, La Porte, Alvin, Pearland, Lake Jackson, Conroe, the Woodlands, Tomball, Kingwood, League City, Humble, Galveston, Clear Lake, Friendswood, Texas City, Katy, West Houston, Orange, Beaumont, Port Arthur, Sugar Land, Missouri City, Victoria, Corpus Christi, Austin, San Antonio, Texas Gulf Coast and Dallas.

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