Dental Malpractice Case Intake Form
Section1
The treatment I am complaining about started on or about:
The location of the dentist I am complaining is:
The dentist who I believe committed dental malpractice on me was a:
I have copies of some or all of the relevant dental records:
I have copies of some or all of the relevant dental x-rays:
Section2
I have been seen by this same dentist for:
The treatment I am complaining about occurred at a:
Section3
The treatment I am complaining about involved:
Section4
The treatment I am complaining about caused the following harm to me:
Section5
The injuries have caused me to:
Is there anything else you would like to add:
Name
My email address is
My telephone number is:
I understand that the transmission of this information does not create an attorney client relationship but is, instead, a request for a free consultation with an attorney about the details of my potential case.