Name

Address

City

State / Province

Zip / Postal Code

Home Phone

Email

Date of Birth

___________________________________________________________________________________

Referred By

Were you referred to a particular attorney in our office?
Yes   If So Who?

Have you spoken with any other attorneys?
Yes   If So Who?

Date Malpractice Committed

Date Malpractice Discovered

Potential Defendant Doctor/Clinic or Medical Facility

___________________________________________________________________________________

Describe what happened to you, including the reason for your visit, type of procedure performed, action/inaction taken, the relevant dates of service an any other information that you consider important

Describe How You Were Damaged

Do you possess any medical records?
Yes
No