PI Intake Form - Medical Malpractice - Foster Graham Milstein & Calisher

Medical Malpractice intake form

Fill out this form if injured by a doctor, dentist or medical professional. Otherwise, choose from one of the following:

Motor Vehicle Crash Premise Liability

Our unified team of dedicated and experienced attorneys can help.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Who may we thank for referring you to our office?

Who was injured in this incident?

Date of birth of injured

Last 4 digits of SSN

Date you discovered issue

Provider name and location that caused your injury

Include address and name of establishment if relevant

Describe the malpractice that caused injury

List the names, phone numbers and addresses of any witnesses who have information about your injury

If you do not know all of this information provide what you know.

What are your injuries and what is your current condition

List your doctors/physical therapists etc. that you have treated with as it relates to this case.

Please include your doctors’ names, addresses and phone numbers, as well as why you are seeing this doctor.

List your health insurance company information AND, if applicable, disability policy information (company, policy number, address and phone) IF you are utilizing your health insurance to care for your injuries

Is this health insurance privately purchased OR is it provided in whole or in part through your employer or your spouse’s employer?

How much time have you missed from your job, and are you utilizing any temporary disability insurance during your recovery?

How much income have you lost? How much do you expect to lose? And how is this lost income determined?

Please list all out of pocket losses you have incurred as a result of this injury.

Please provide any other information you believe will assist our office in resolving this matter.

Comments

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