PARIENTE LAW FIRM, P.C.

DUI Client Intake Portal

1635 Village Center Cir., Suite 280, Las Vegas, NV 89134 · (702) 966-5310

Please complete the intake below. Required fields must be completed before submission.

1. Client Information

Last Name *

First Name *

Middle

Date of Birth *

Age

SSN

Street Address *

City *

State

ZIP *

Cell Phone *

Home Phone

Work Phone

Email *

Place of Employment

How Long?

Occupation

Marital Status

Family / Military

Spouse’s Name

Spouse’s Phone

May spouse have information regarding your case?

YesNo

May anyone else in your family have information?

YesNo

If yes, list names and phone numbers

Are you or have you been in the military?

YesNo

Branch

When was service?

Honorable Discharge?

2. DUI Arrest / Case Background

Date of Arrest / Hospitalization *

Time

AM/PM

Valid Driver’s License?

State

Commercial Driver’s License?

Concealed Weapons Permit?

Pilot’s License?

Chemical Test

What best describes your case? *

Blood Test
Breath Test
Urine Test

REFUSAL — I refused all chemical testing

Refusal selected: Please answer these additional questions.

Were you asked more than once to submit to testing?

Did the officer read the implied consent warning?

Was a warrant obtained?

Was blood eventually taken anyway?

Explain what happened during the refusal

Accident / Arresting Agency

Was there an accident?

YesNo

Were there injuries to anyone other than yourself?

YesNo

Briefly explain the accident/injuries/property damage

Arresting Organization

Arresting Officer’s Name

Weather

Rain
Windy
Cold
Hot

Other weather details

3. Traffic Stop / Field Sobriety

Why were you stopped?

Did the officer tell you why you were stopped?

Field sobriety tests requested/performed

HGN / Eye Test
Walk-and-Turn
One-Leg Stand
Alphabet
Counting
Refused Field Sobriety Tests

Describe what happened during field sobriety testing

Were you read Miranda rights?

Were you questioned after arrest?

4. Medical History

Using prescription, non-prescribed, controlled substances, or OTC medications?

YesNo

If yes, what were they?

What were these drugs being taken for?

Physical defects/ailments that may affect field sobriety tests or appearance?

Recent surgeries?

If yes, when/what for?

Speech Impediment?

Heart Condition?

Blood Thinners?

Diabetes / Hypoglycemia?

Acid Reflux?

Treated for Acid Reflux?

False Teeth / Partials?

Physically ill at arrest?

Contacts / LASIK?

5. DMV Acknowledgment / Authorization

I acknowledge that I am responsible for notifying DMV of my correct mailing address and immediately notifying Pariente Law Firm, P.C. if I receive notice from DMV that my license is being revoked.

Driver’s license address status *

Convicted of a moving violation in the last 12 months?

I authorize my attorneys, their agents, and staff to access DMV websites and contact DMV/license review to obtain information regarding my state-issued driver’s license and personal driving record.

Client Electronic Signature *

Date *

6. Insurance / Accident Authorization

If there was an accident, it is important to contact your insurance carrier and provide this office information regarding any injuries that may have been sustained.

Insurance Company

Claim Number

Adjuster’s Name

Adjuster’s Phone

Adjuster’s Fax

I authorize my insurance company to release any and all information requested by my attorneys or their representatives.

Client Electronic Signature

Date

7. Uploads / Notes

Upload driver’s license
Upload citation / ticket
Upload temporary license / DMV notice
Upload insurance card / claim paperwork
Upload photos, videos, bond paperwork, or other documents

Notes / Remarks

By submitting, I certify the information provided is true and accurate to the best of my knowledge.

Required fields must be completed before this will send.

Test Form for PLF

PARIENTE LAW FIRM, P.C.

1. Client Information

Family / Military

2. DUI Arrest / Case Background

Chemical Test

Accident / Arresting Agency

3. Traffic Stop / Field Sobriety

4. Medical History

5. DMV Acknowledgment / Authorization

6. Insurance / Accident Authorization

7. Uploads / Notes

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