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Medical Malpractice Information Form
TYPE OF CASE
Birth Injury
Heart Attack
Cancer Diagnosis
Stroke/ Brain Injury
Eye Surgery
Medication Error
Spinal Cord Injury
Surgical Mistake
Retained Foreign Object
Other
INJURED PARTY INFORMATION
Callers Name:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone  
Work Phone  
Other Phone  
E-Mail Address:
FACTS AND DAMAGES
Date of Incident:
Date Discovered Problem:
City Incident Occurred:
Describe how the probelm came about:
Did this result in death:
If no, what are the resulting injuries/disabilities:
Do you anticipate furture medical problems:
Will you require futher surgery(ies):
Briefly describe the medical condition/problems prior to this incident:
Have you made a formal complaint to doctor/hospital:
Has this ever gone before Medical Review Panel:
Doctor(s) Involved:
Pharmacist/Pharmacy Involved:
Hospital Involved:
Do you have your medical records with reference to this incident:
Have you contacted another law firm in reference to this incident:
How did you hear about our firm:
Additional Comments:
Security Code*:
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