*Your Name:

*E-mail:

Street Address:

City:

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*Phone Number:

Best time to call: DayNight

Personal Injury Case Facts

1. Have you, a family member, or some other person you know suffered a serious drug-drug interaction or an adverse drug reaction caused by a doctor or some other healthcare provider who was negligent (or somehow wrong) in their treatment? YesNo

2. What was the date of the alleged medical negligence or medical error:

3. In what state did the alleged medical negligence or medical error occur:

4. What is your date of birth:

5. Have you filed a lawsuit concerning this medical negligence or medical error? YesNo

Describe in summary the medical treatment which you have been told by a doctor was negligent or that you suspect was negligent:

Wrongful Death Case Facts

1. Has a medical doctor ever told you that medical negligence or a medical error was involved with the death of a family member or someone else you know? YesNo

2. What was the date of death:

3. What was the date of the medical treatment which is thought to be allegedly negligent or in error:

4. In what state did the decedent reside at the time of death?:

5. Have you or someone else filed a lawsuit concerning this death? YesNo

6. What is your relationship to the decedent?:

7. How old was the person at the time of death?:

Describe in summary the medical treatment which you have been told by a doctor was negligent or that you suspect was negligent:

Additional Information

Please enter any additional information about this claim, as well as any comments or questions you may have, in the following space: