Medical Malpractice Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Details of Your Legal Matter What type of negligence is alleged to have occured? - Select One - Misdiagnosis Administration of the wrong medication Failure to properly inform the patient of risks or alternative treatments Other (see Additional Details field) What type of medical care was being provided at the time that the negligence is alleged to have occured? When was your medical care provided (Enter month and year)? Name of the medical professional who caused your injury When did you become aware of these injuries? - Select One - Within the Last Month 1-2 Months Ago 2-3 Months Ago 3-6 Months Ago 6-12 Months Ago More than 12 Months Ago Approximate medical bills to date related to the injury Additional Details General Info Business First Name * Last Name * Email * Home Phone Work Phone Cell Phone Preferred Contact Method - Select One - Email Home phone Work phone Cell phone Anti Spam QuestionPlease answer the simple addition problem below. 2 + 6 = * The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk. If you are a human and are seeing this field, please leave it blank.