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Medical Malpractice cases require a significant amount of information to follow up on. Please complete the form below so we can further investigate your medical malpractice claim.
Date of Birth*
StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Date of Injury*
A. Do your injuries prohibit performance of any daily living activities?example: Can you brush your hair? Perform household tasks such as cleaning and cooking?) If so, for how long have you been unable to perform these activities?YesNo
B. Do you have a history of treatment for chemical dependency?YesNo
C. Do you have any hobbies or interests which are limited due to your injury?YesNo
D. Do you have a history of psychiatric or psychological treatment?YesNo
E. Do you have a criminal record?YesNo
F. Have you ever made any previous claims for personal injuries, medical malpractice, workers’ compensation, or social security disability?YesNo
Do you have any Injury Photos to upload?YesNo
Do you have any accident photos to upload?YesNo
Do you have any x-rays to upload?YesNo
Medical RecordsYesNo
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