Name Phone Number Address City State Zip Email Address Date of Birth Marital Status SingleMarriedPartneredDivorcedWidowed Children YesNo Any Children Under the Age of 25? YesNon/a Please provide a chronological description of the events leading to and including your claims of medical malpractice and describing the injuries you received because of this malpractice. Please include all pertinent dates, the names of involved physicians, all pertinent symptoms and diagnosis, and the treatment initiated for each condition. When do you believe the negligence occurred? Who do you believe was negligent? How was the healthcare provider negligent? What are your injuries? Are they continuing injuries? YesNo Prognosis for recovery? Did any subsequent healthcare providers criticize the care provided by the negligent healthcare provider? YesNo If yes to the above, what did they say? Do they have a copy of the medical records? YesNo
