Medical Malpractice

Caller Name (if not injured party):

Caller Email:

Caller Phone Number:

Relationship Of Caller To The Injured:

Potential client Info

Full Name Potential Client

Prefix *

Mr.

Ms.

Phone *

Email

No Email Provided

No Email

Address

Street Address

City

State

Country

Postal code

Date of birth

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

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:

Describe any follow-up care or treatment after the alleged malpractice:

HEALTH INFORMATION

Medical Providers:

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

DISABILITY

Are you receiving any form of disability because of this incident:

Yes

No

If yes, what conditions are you receiving disability for:

If yes, what disability benefit(s) are you receiving:

Social Security Disability:

Yes

No

SSI:

Yes

No

Unkown

Employment Related Disability:

Yes

No

Other:

Yes

No

Are you receiving any form of disability for other conditions not related to this incident:

Yes

No

If yes, what conditions are you receiving disability for:

If yes, what disability benefit(s) are you receiving:

Social Security Disability:

Yes

No

Employment Related Disability:

Yes

No

Other:

Yes

No

EMPLOYMENT HISTORY

Are you currently employed?

Yes

No

If so, state:

Name of employer:

Occupation:

Have you experienced any lasting disabilities or conditions affecting your work capacity?

Yes

No

If yes, please describe:

Call Notes

General Notes During Intake:

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