Virtual Clinic Disclaimer Form Please fill out the required information. "*" indicates required fields Name* First Last Phone*Email* Enter Email Confirm Email Are you a US Citizen?* Yes No What is your legal issue?*Authorization* I authorize you to give my information to a volunteer attorney, for the purpose of providing limited scope representation in the form of counsel and advice. I understand that the information, advice or other help the lawyer gives me today, is based on the information that I give the lawyer. The lawyer has not investigated the information, claims, or facts of my case and is relying on me to make my best effort to give truthful, accurate, and complete information. I understand that the help I receive from the lawyer is limited to information, advice, and/or help filling out forms for today only. The lawyer is not agreeing to represent me in any court case or proceeding and will not enter an appearance as my lawyer.. I have read and understand this notice and agree with the terms of this representation. Signature (Please type your full legal name.)*
