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CLIENT INFORMATION REPORT FOR MEDICAL-DENTAL MALPRACTICE
 
       
* Name

   

Home Address

Home City, State & Zip

Phone

Fax

* Email

Business Address

Business City, State & Zip

Employer

Business Telephone

Business Fax

Birth date

SSN:

Marital status

Spouse's Name

MEDICAL/DENTAL NEGLIGENCE
Names, addresses, dates of treatment, and treatment performed by all physicians or dentists who may have been negligent: PROVIDE FULL NAMES AND ADDRESSES

Brief description of negligence:

Date you first suspected negligence

How?

Date you first knew of negligence

If another health care provider advised you that negligence was or may have been committed, state: Name and address of dentist who advised you

When advice was given

What was said

INJURIES AND CORRECTIVE DENTAL/MEDICAL TREATMENT
List every illness or injury, even if slight, which you believe was caused or made worse by negligence

Names, addresses, and dates of treatment of dentists or physicians who have treated or will treat you for negligently caused injuries

List treatment performed or recommended by dentists or physicians named in number 12 above. Indicate present status of treatment, i.e. whether ongoing, completed, or planned, and costs of treatment

List all other dental or expenses incurred as a result of the negligence (include drug prescriptions)

WAGE LOSS
Are you claiming past and/or future lost wages?

Yes
No
 

(If yes, answer the questions below. If no, skip to signature)
Occupation

How Long?

Employer:

Amount of lost wages and how you calculated the loss

Any other lost wages due to use of sick leave benefits or other benefits, or time made up due to dental visits, and how you calculated the loss

* I certify the above information to be true and complete to the best of my knowledge and belief in order to assist the attorney in evaluating my case.
Dated

Signed


 
 

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