| Your Name: |
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| * Email Address: |
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| Your Home Address: |
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| City: |
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| State: |
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| Zip: |
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| Home Phone: |
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| Business Phone: |
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| Pager Phone: |
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| Mobile Phone: |
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| Fax Number: |
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| Contact Preference (How do you want to be contacted?): |
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| Date of Birth: |
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| Driver's License Number and State: |
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| Occupation: |
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| Place of Employment: |
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| How did you learn about our practice? |
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Please describe any prior military service:
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Describe any charity, civic or community organizations you are involved with:
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When and where is your next court date:
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Please tell us the date, time and location of your DUI arrest:
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Which police agency arrested you:
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The arresting officer(s) name(s) (If you remember):
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If you have any prior convictions for DUI or "wet reckless," please give us the date, county and charges:
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If the officer pulled you over, did he explain why?:
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Did the officer take your driver's license or give you a paper called Administrative Per Se Order of Suspension/Revocation, Temporary Driver License Endorement?
Yes
No |
Have you contacted the DMV as requested on the Administrative Per Se Order?
Yes
No
If not, please call us toll free at 888-327-4652. |
If you have contacted the DMV within the 10 day limit, when is your appointment (date and time)?:
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Approximately how many minutes went by from the time you were arrested (when they handcuffed you) until you arrived at the chemical test (blood, breath or urine test)?:
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Approximately how many minutes went by from the time you arrived at the chemical test location until you took the first chemical test (blood, breath or urine test)?:
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Please describe the number of drinks you consumed, what you consumed and when you consumed it for a period of 8 hours before the arrest:
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Please describe what food you ate and when you ate it for a period of 8 hours before the arrest:
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Please select the field sobriety tests you were requested to perform? (Check all that apply):
Follow a pen, finger or other object with your eyes, not moving your head
Stand with your head tilted back and eyes closed, feet together, cout to 30
Stand on one foot for a period or time
Pat your hands together
Count on your fingers
Say or write the ABC's
Walk a straight line or heel-to-toe
Touch your nose with your finger
Other |
Please describe any medical conditions, injuries or physical constraints from which you suffer (especially those that may have affected your ability to perform the field sobriety tests):
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Do you suffer from GERD, acid reflux or frequent heartburn? Describe:
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Do you wear braces, dentures or have active cavities? Describe:
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During the several days leading up to the arrest, were you exposed to any solvents, compounds or industrial chemicals? Explain:
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Describe any allergies you suffer from and whether this has been diagnosed:
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Did you blow into a handheld breath machine prior to the officer arresting you?:
Yes
No |
If you know, what was the result of the hand-held breath test?
I don't know/not applicable |
Did the officer advise you that you could refuse to take the hand-held breath test?
Yes
No
I don't know/not applicable |
Please select the type of chemical test you took (or whether you took a chemical test at all):
Blood
Breath
No Chemical Test Taken |
What were the results of the test, if you know?
I don't know/not applicable |
How much time elapsed between finishing your last drink and taking the chemical test?
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