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Medical Malpractice Form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • List all doctors, hospitals, physical therapist, chiropractors, or others who have treated you for this injury:

  • Employment Information

  • Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider

  • General instructions:

    1. Take photographs of your injuries, if possible.
    2. Give no information to anyone other than our office.
    3. Forward copies of all bills or receipts for hospital, x-ray, loss of earnings and medical reports.
    4. Additional instructions will be given to you based on your individual situation.