Potential Medical Negligence Claim

Please fill out this form as completely as possible. All information you provide is confidential. After we have received your completed form, an attorney will review your claim and determine whether or not this firm can represent you. We will contact you within one week of receiving your completed form to inform you of our decision or to request additional information.

Your Name
Injured or deceased persons name if you are calling on behalf of a friend or relative
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address
Phone Number
Email Address
Age of injured or deceased person
Who is the medical care provider and or hospital where this occurred
When did this happen
MM slash DD slash YYYY
Why do you think you or a family member were the victim of medical negligence
Describe your injuries

NOTE: The completion of this form for communication with the firm does not establish an attorney-client relationship.

Potential Medical Negligence Claim

Potential Medical Negligence Claim

Verdicts & Settlements

Wrongful Death: $5,500,000

Civil Rights: $1,230,000

DSS Settlement: $1,625,000

Medical Malpractice: $5,950,000

Personal Injury: $1,100,000

Personal Injury: $10,755,000

Personal Injury: $1,000,000

Personal Injury: $1,300,000