Malpractice Case

Step 1 of 48

Email(Required)

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Cell Phone#

Home phone #

Please give us all your previous addresses with the dates of lived there.

Who do you live with (list all)

If this is a wrongful death claim, list your name and the loved one or the estate in which you are representing.

Decedent's name (if not you)

First Last

Relationship to decedent (if not you)

Spouse

Child

Parent

Other

Was you or your loved one place on a ventilator or other breathing devices?

Yes

Maybe

What treatments did you or they receive that you feel were not appropriate?

Please upload any medical records you may have.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, eml, Max. file size: 128 MB.

Do you believe Remdesivir was giving to you or your loved one?

Yes

Not Sure

Were you given any additional information regarding having your loved one receive Remdesivir (Veklury) either verbally or in written form?

Yes

Maybe

Date Incidents or hospitalization occurred.

DD slash MM slash YYYY

End Date Incidents or hospitalization that resulted in death or in injury

DD slash MM slash YYYY

Date aware of any WRONGDOING, if different than date of incident

DD slash MM slash YYYY

Please explain

What is the identity of the doctor and/or hospital in question?

What occurred that leads you to believe a health care professional caused you harm?

Has any health care professional apologized for the results of you/their care?

Yes

Whom?

Has anyone told you that the medical care you/they received caused an injury?

Yes

Was this physician assigned to your loved one by a hospital?

Yes

Not Sure

Whom assigned him/her?

Give us a complete history and if you have dates please provide them as you answer the following question.

Why did your loved one go to the doctor/hospital and what happened in chronological order.

Did you file out any complaint forms with the hospital or with any other agency or survey after the incident?

Yes

Not Sure

Have you contacted any other attorneys or signed a contract with another attorney?

Yes

Not Sure

Please explain...

Have you ever seen the complete hospital bill for the stay?

Yes

Not Sure

Have you filed a lawsuit or been a part to a lawsuit?

Yes

Not Sure

Please explain

Has anyone has contacted you from either the provider’s insurance carrier or the provider’s legal department?

Yes

Not sure

Medical Insurance

Name of your/their PRIMARY medical insurance company:

If you have Medicaid, please supply information like name, address, city, state and zip code as well as ID #

Treatment, describe in the order of occurrence all treatment leading up to incident as well as any thing explained to you, in direct "quotes" and who said those it and their position at the medical institution, if you know it. Just as John Doe, MD, or Jane Doe, RN.

Name, address and Telephone of employer or personnel department at the time of incident

Length of employment, years and months

Total amount of income lost to date due to incident (if applicable)

Out of Pocket expenses: List everything you have receipts for.

Have you ever made a claim for malpractice or work related injuries at any time, including workers compensation or industrial insurance.

Yes

Maybe

Have you ever filed a claim for Social Security benefits due to an injury

Yes

Not sure

Have you ever been charged with or convicted of a criminal offense?

Yes

Maybe

Have you ever filed a lawsuit in any court?

Yes

Maybe

Please tell us about when and where and why?

WRITINGS

Do you have any writings of any kind, including, but not limited to: notes, calendars, diaries, journals, emails, text messages, blogs, social-network or other online postings, Facebook pages, electronically stored information, or any other documents or electronic media, which include entries by you or your family members related to your medical condition or the medical care and treatment at issue?

Yes

Please tell us about what you have that you can share with the us and the court?

SOCIAL NETWORKING

Do you have any social networking accounts, such as Facebook, LinkedIn, MySpace, or do you operate or participate in a blog, microblog (e.g., Twitter), photoblog, chat-room, message board, personal websites, etc?

Yes

Please list, providing URLs (web links), if possible

Have you ever been quoted or profiled by any newspaper, magazine, website, or other entity or person that is likely to have an online presence?

Yes

Please describe, providing URLs (web links), if possible

EMAIL

Do you have more than one email account?

Yes

Maybe

If you did have more than one, please list ALL of your previous emails

PHOTOS

Do you have any photographs, videos, charts, drawings, diagrams, or other representations which in any way pertain to incident?

Yes

Maybe

Please Upload

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, eml, Max. file size: 128 MB.

Is there any other information you would like us to know about?

Enter your contact information

Name

First Last

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Referred By?

Referred By? : Other

Were you given informed consent, verbally, or in writing?

Yes

If yes, do you have a printed copy of what you were presented that day?

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docs, docx, Max. file size: 128 MB.

Medical Insurance

WRITINGS

SOCIAL NETWORKING

EMAIL

PHOTOS

Enter your contact information

Referred By?

Warp Speed Legal

Questions?

My Legal Issue

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