Your Contact Information

a. Basic Information

Full Name *

Email *

Phone *

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Date of Birth *

b. Location

In which U.S. state did the medical incident primarily occur? *

When did the medical incident occur? *

When did you first realize or were told something went wrong? *

What was the original reason for seeking care? *

What type of medical care or facility was involved? (Select all that apply) *

Hospital or inpatient stay

Surgery or procedure (operation, anesthesia, etc.)

Emergency room or urgent care

Outpatient clinic or private doctor

Diagnostic testing (MRI, biopsy, etc.)

Medication or prescription management

Nursing home or long-term care

Childbirth/delivery (OB/GYN, hospital birth)

Other

Please describe briefly what happened and what you believe went wrong. *

What do you believe was the main medical mistake? *

“Never event” (e.g., wrong surgery, wrong patient, wrong site)

Missed or delayed diagnosis / birth-related error

Medication, anesthesia, or monitoring failure

Infection or equipment malfunction

Other / unclear cause

Do you have any medical records or documentation showing what happened? *

Yes, they clearly show errors

Yes, but I’m not sure if they prove errors

Some, but incomplete

None

Has another medical professional reviewed your case? *

Yes, confirmed malpractice or below-standard care

Yes, suggested it might be malpractice

What is the most serious harm or injury caused by the incident? *

Death

Permanent brain damage, paralysis, or organ loss

Loss of major sense (vision/hearing) or infertility/disfigurement

Chronic pain or multiple corrective surgeries

Temporary but serious injury

Minor or emotional distress only

Please explain the primary harm or injury with details? *

What is the long-term negative result of this incident? *

Ongoing Pain

Injury

Work/Family Impact

What was the approximate age of the affected person at the time? *

Under 40 years old

40–60 years old

Over 60 years old

How has this incident affected your ability to work? *

Permanently unable to work

Unable to return to previous job or career

Can work, but with reduced hours/duties/pay

Missed over 3 months of work but recovered

No work impact

What was your occupation and approximate annual income before the incident? *

High-earning professional ($150K+)

Mid-level professional/skilled trade ($75K–150K)

General labor/service (<$75K)

Do you have a spouse? *

Yes

Do you have dependants/children? *

Yes

Do you have access to your medical records portal? *

Yes

How has this affected your daily life or independence? *

Requires 24/7 care

Needs daily help (bathing, eating, etc.)

Cannot live independently (e.g., assisted living)

Major limitations but mostly independent

Minor limitations or full recovery

How clearly can you describe what went wrong and how it caused harm? *

Very clear and well-documented

Somewhat clear but missing details

Unclear or uncertain

How long have you been unable to work at full capacity? *

Are you currently being treated by a physician? *

Yes

Do you have any disability insurance? *

Yes, private/personal

Yes, employer-provided

Not sure

Have you applied for Social Security Disability (SSDI/SSI) or other benefits? *

Yes, denied (appeal possible)

Pending

Yes, approved

Is the affected person currently under the age of 65? *

Yes

Have you discussed your case with an attorney? *

Yes