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Areas of Practice
Our Team
Contact
Medical Malpractice Intake
Please complete the form below if you believe you have a medical malpractice issue. We will do our best to get back to you promptly.
Client Name
*
Your Name
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Injured Party
*
First Name
Last Name
Date of Injury
*
Date of Injury
MM
DD
YYYY
Date of Birth
*
of deceased
MM
DD
YYYY
Facts of the Incident
*
Please include all details
Name of all parties responsible for injury
*
Has another doctor told you who was directly responsible for the injury?
*
Please select option below
Yes
No
I am not sure
If yes, please provide details
Statute of Limitations
*
On what date will this opportunity expire
MM
DD
YYYY
Health at time of injury
*
If unknown, write "unknown"
Previous Medical History
*
Provide detailed summary
Employment History
*
Please list all places of employment as well as titles, positions and length of time. If unknown, write "unknown"
Previous Legal Claims or Injury Claims Filed?
*
First Name
Last Name
Thank you!
