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Medical Malpractice Case Intake Form

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  • Step Final


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:


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:

Please Explain:


The malpractice caused injury to my:

Please Explain:


The injuries have caused me to:

Please Explain:

Additional Information:


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.