Name

Email Address

Phone Number

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

When did you begin the medical treatment in question? When did the treatment end?

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

Has any health care professional apologized for the results of your care?
Yes  No 

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

Did anyone discuss the risks of the treatment or medication at issue with you?
Yes  No 

Did you sign any documents acknowledging you were aware of the risks of treatment?
Yes  No 

Did you sign an arbitration agreement prior to commencing the medical care at issue?
Yes  No 

Did you have a pre-existing relationship with the doctor in question?

Was the physician in question assigned to you by a hospital?
Yes  No 

Why did you go to the doctor/hospital? What happened?

What is the current status of that condition?

What were you diagnosed with?

What treatment did you receive? What were the results of that treatment?

Are you currently under a doctor's care? For what?

What is your diagnosis? Prognosis?

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