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:

general dentist specialist I’m not sure

I have copies of some or all of the relevant dental records:

Yes No

I have copies of some or all of the relevant dental x-rays:

Yes No

Section2

I have been seen by this same dentist for:

more than 1 year less than 1 year I’m not sure

The treatment I am complaining about occurred at a:

hospital private office, outside of a hospital

Section5

The injuries have caused me to:

experience discomfort and pain

lose time from work

reduce my activities

Other - Explain Below

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.

Disclaimer

l understand and agree.

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