COMMERCIAL LITIGATION

EMERGENCY MALPRACTICE

FAILURE/ DELAY OF DIAGNOSIS

NO INFORMED CONSENT

ANETHESTIC ERRORS

Do I Have A Case

Disclaimer: Submitting your question via e-mail does not create an attorney client relationship and should not be relied upon as such.

YOUR INFORMATION

*First name:
Last name:
Address:
*Date of Birth:	(MM-DD-YYYY)
Apartment/Floor:
City:
State:
Zip code:
*E-mail address:
Phone:

CLIENT INFORMATION

First name:
Last name:
Address:
Apartment/Floor:
City:
State:
Zip code:
E-mail address:
Phone:

Please detail your question here:

HELPFUL HINTS

The following list of questions will help you organize events and information related to an accident and/or incident:

FACTS OF THE MATTER

Type of case:

Date of incident:

Injuries:

What happened?:

Have you contacted another attorney?
YES NO

If yes, who?

REFERRAL SOURCE
Television
Yellow Pages
Newspaper
Attorney
Past/present client
Other Client
Other

ADVERSE INFORMATION

Adverse Party:
Adverse Insurance:
Adjuster's Name:

Contact with adverse insurance?
YES    NO

Liability
Poor    Excellent

TREATMENT
Medical Provider(s):

Hospitalized?
YES    NO

Approximate amount of medical bills:

ISSUES AND COMMENTS:

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