*Name:

Address:

City:

State, Zip:

Phone Number:

Fax Number:

*E-mail Address:

DOB:

SS#:

Marital Status:

Kids:

How Many Kids:

Education:

Military:

Date of Treatment:

Doctor/Specialty/Location/Referral:

Treatment for What:

Doctor Did What Wrong:

Subsequent Treatment:

Who?:

What - Corrective Treatment?:

Any Statements Against 1st Doctor?:

Any Complaint Made to Doctor?:

Written or Recorded Statements to Anyone?:

Do They Have Your Medical Records:
Yes   No

Has This Case Been Reviewed By Another Attorney?
Who? When?:

Damages From Medical Negligence:

Bodily Damages:

Special Damages (Lost wages, etc.)

Disability?

Medical Insurance/Disability Insurance -
Out of Pocket Expenses?:

Notes: