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Dental Malpractice Case Intake Form

  • Step1
  • Step2
  • Step3
  • Step4
  • Step Final

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:

Please Explain:

Section4

The treatment I am complaining about caused the following harm to me:

Please Explain:

Section5

The injuries have caused me to:

Please Explain:

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.

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