Medical Malpractice Case Evaluation Form
Please complete this form to share the details of your potential medical malpractice matter for an initial case review.
Client and Case Overview
Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
*
Phone
Email
Text Message
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best Time to Reach You
Hour Minutes
AM
PM
AM/PM Option
Relationship to the Patient
Medical Provider or Facility Involved
*
Date of Incident or Approximate Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident and Injury Summary
Brief summary of the incident
*
Type of alleged issue
*
Please Select
Misdiagnosis
Delayed diagnosis
Surgical error
Medication error
Anesthesia issue
Birth injury
Failure to treat
Failure to monitor
Hospital/ER care issue
Other
Body area or condition affected
*
Please Select
Head
Neck
Back
Spine
Chest
Abdomen
Arms/Hands
Legs/Feet
Whole body
Other
Current status of injury or harm
*
Please Select
Fully resolved
Improving
Ongoing but stable
Worsening
Unknown
Current severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Did emergency treatment or hospitalization occur?
*
No
Emergency room only
Hospitalized
Both
Unknown
Immediate consequences
Missed work or school
Additional procedures
Ongoing pain or symptoms
Temporary disability
Permanent impairment
Emotional distress
Other
Treatment, Records, and Prior Actions
Names of treating providers or facilities
Are relevant medical records available?
*
Yes
No
Partially
Unknown
Has the client already contacted another lawyer?
*
Yes
No
Unknown
Has a complaint been filed with any medical board or agency?
*
Yes
No
Unknown
Are there any witnesses?
*
Yes
No
Unknown
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