Medical Malpractice Questionnaire
Please answer the following questions and as detailed and provide as much information as possible. Once the information has been submitted, it will be reviewed in-house and someone from our office will follow up with you.
Please be aware that a statute of limitations applies to this situation, meaning there is a deadline to bring a claim. Once the statute of limitations expires, any claim would be time-barred.
Please complete the information below:
Your First Name *
Your answer
Your Last Name *
Your answer
Your Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Your Home Phone Number (if no home phone number, put N/A) *
Your answer
Your Cell Phone Number (if no cell phone number, please N/A) *
Your answer
Your Email Address (if no email address, put N/A) *
Your answer
Your Date of Birth
MM
/
DD
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YYYY
If you are NOT the injured person, please complete the information below:
Relationship to you
Your answer
First Name
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
INCIDENT DETAILS
Did the medical malpractice result in death? If so, what was the date of death?
Your answer
Please explain as specifically as possible what injury(ies) and disability(ies) resulted from the medical malpractice and the current condition. *
Your answer
When did the malpractice occur (as specific as possible mm/dd/yyyy)? *
Your answer
Please provide the name of the facility where the malpractice took place.
Your answer
Who do you believe is responsible for the malpractice? If the responsible party is an individual, please state their name(s) and position/title. *
Your answer
What do you feel they did wrong? In your own words, please explain what happened.
Your answer
What medical conditions did you or your loved one have before this event of malpractice? Please describe.
Your answer
Do you have any of the medical records?
Your answer
Are you a current or former smoker?
Your answer
Do you or did the injured party have any of the following conditions? *
Required
How did you hear about us? (for example: Internet search, family member, friend, lawyer, TV, print ad, Facebook) *
Your answer
Were you referred to a specific lawyer? If so, please provide their name. *
Your answer
Are you currently represented in this matter by another lawyer? If so, please provide their name. *
Your answer
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