MEDICAL AND NEGLIGENCE REVIEW

 
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Medical Negligence
Malpractice Questionnaire

This questionnaire is a part of your confidential attorney-client file. Therefore, it is important and in your best interest to answer all of the questions and material fully and in very great detail. Even if something has occurred around the time of the claimed negligence and you don’t know if it s relevant please include it. It is easier and more efficient to exclude an irrelevance than it is to be surprised by an unknown relevant fact. Take your time, be sure you print and save your answers for your records and be completely honest for this confidential document. It will help you and me process your claim, as a matter of fact the advisory opinion you get from me will be only as accurate as the information you provide me.

Discovery of the Possible Malpractice

Date of Discovery
Last Name   First   MI
Address
City    State   Zip
 Phone Home
Work
Cell  
E-mail
 
Date of Birth
Marital Status  
Spouse Name        DOB

Date  of Injury Due to Malpractice.

 
State in your own words why you feel you have a possible  negligence/malpractice claim.


 

Please explain what acts of the health care provider you feel constituted malpractice?
 
What injuries and disabilities do you have that you feel are caused by the malpractice?

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MEDICAL NEGLIGENCE REVIEW
Phone: (248) 540-4557
  
E-mail:
rjg@medicalnegreview.com