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Medical Malpractice Case Intake Form

  • Step1
  • Step2
  • Step3
  • Step4
  • Step Final

Section1

The treatment I am complaining about started on or about :

I believe that medical malpractice was committed on me by:

Please Explain:

The location of the doctor/hospital I am complaining about is:

Section2

I believe that the medical malpractice that occurred involved:

Explain:

Section3

I have copies of some or all of the relevant medical/hospital records:

As a result of the medical malpractice, I needed:

Please Explain:

Section4

The malpractice caused injury to my:

Please Explain:

Section5

The injuries have caused me to:

Please Explain:

Additional Information:

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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