WD Medical Malpractice

Caller Name (if not injured party):

Caller Phone Number:

Caller Email:

Relationship Of Caller To The Injured:

Potential client Info

Full Name *

Prefix *

Mr.

Ms.

Phone *

Email

No Email Provided

No Email

Date of birth

Address

Street Address

City

State

Country

Postal code

Okay To Text? *

Yes

No

Okay To Email? *

Yes

No

Have You Consulted With Any Other Law Firms?

Yes

No

If Yes, who?

If Yes, Are You Currently Represented By An Attorney For This Matter?

Yes

No

If Yes, Who Currently Represents you?

If we are not able to assist, may we send your information to a referral source?

Yes

No

DECEDENT’S INFORMATON:

Decedent Name:

Caller’s Relationship to Decedent:

Decedent Date of Birth/Age:

Decedent Date of Death:

FACTS OF INCIDENT:

Date of Injury:

Hospital/Facility Name:

City and state:

Physician Name (if known):

Briefly describe the medical negligence or what you feel was done wrong:

HEALTH INFORMATION:

Medical Providers:

Prior Health Conditions (such as chronic conditions, previous hospitalizations, surgeries, or serious illnesses):

DISABILITY:

Was Decedent receiving any form of disability at the time of this incident:

Yes

No

Unkown

If yes, what conditions were they receiving disability for:

If yes, what disability benefit(s) were they receiving:

Social Security Disability:

Yes

No

Unkown

SSI:

Yes

No

Unkown

Employment Related Disability:

Yes

No

Unkown

Other:

Yes

No

Unkown

POTENTIAL BENEFICIARIES:

List of surviving Class 1 family members (mom, dad, child(ren), and/or spouse):

Any children of decedent under the age of 18?

Yes

No

Unkown

Call Notes

General Notes During Intake:

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