* Your Name:
* Email Address:
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Contact Preference (How do you want to be contacted?):
Date of Birth:
Driver's License Number and State:
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How did you learn about our practice?
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Please describe any prior military service:
Describe any charity, civic or community organizations you are involved with:
When and where is your next court date:
Please tell us the date, time and location of your DUI arrest:
Which police agency arrested you:
The arresting officer(s) name(s) (If you remember):
If you have any prior convictions for DUI or "wet reckless," please give us the date, county and charges:
If the officer pulled you over, did he explain why?:
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?
Have you contacted the DMV as requested on the Administrative Per Se Order?
If not, please call us at 702-333-3673.
If you have contacted the DMV within the 10 day limit, when is your appointment (date and time)?:
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)?:
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)?:
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:
Please describe what food you ate and when you ate it for a period of 8 hours before the arrest:
Please select the field sobriety tests you were requested to perform? (Check all that apply):
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):
Do you suffer from GERD, acid reflux or frequent heartburn? Describe:
Do you wear braces, dentures or have active cavities? Describe:
During the several days leading up to the arrest, were you exposed to any solvents, compounds or industrial chemicals? Explain:
Describe any allergies you suffer from and whether this has been diagnosed:
Did you blow into a handheld breath machine prior to the officer arresting you?:
If you know, what was the result of the hand-held breath test?
Did the officer advise you that you could refuse to take the hand-held breath test?
Please select the type of chemical test you took (or whether you took a chemical test at all):
What were the results of the test, if you know?
How much time elapsed between finishing your last drink and taking the chemical test?
