- Step Final
The treatment I am complaining about started on or about :
I believe that medical malpractice was committed on me by:
The location of the doctor/hospital I am complaining about is:
I believe that the medical malpractice that occurred involved:
I have copies of some or all of the relevant medical/hospital records:
As a result of the medical malpractice, I needed:
The malpractice caused injury to my:
The injuries have caused me to:
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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