ZIP Code or City: *

Theseoptional questionswill provide potential attorneys with specific details about your case.

Important - Many personal injury law cases require action within a limited time-frame, called a statute of limitation. Please speak with your selected attorney for more information.

Date or timeperiod when the medical malpractice was discovered:

The claimed injury occurred on this date:

As a result of the medical malpractice, there was:

No injury

Minor injury

Disfigurement or cosmetic injury

Short term loss of physical ability

Long term or permanent loss of physical ability

Possibility of future harm

The status of medical treatment is:

No treatment yet

Still receiving treatment

Stopped treatment but need to restart

Treatment completed

I don't know

The medical costs to date are approximately:

I don't know

There are no medical costs

Was there a prior injury at the same part of the body?:

If yes,on this date or over this timeperiod:

The health care provider responded to the problem by:

Giving a partial or full refund

Directing more treatment

Denying wrongdoing

I did not complain

The health care provider is affiliated with the following medical organization:

Solo practitioner

Medical group

Hospital

HMO / Group benefit

Free clinic

Government facility

I don't know

The injured party believes they have insurance that will cover this injury:

Yes

I don't know

The injured party believes that the other party has insurance that will cover this injury:

Yes

I don't know

Occupation:

The injured party missed this time from work or will likely miss this time from work because of the injury:

No work missed

This number of work days:

This number of work months:

Injured person will return to work on this date:

Injured person is still receiving treatment and is unsure when will return to work

I don't know

This number of work days:

This number of work months:

Injured person will return to work on this date:

Amount of lost work income to date is:

No lost work income

I don't know

$ value:

Age of Patient:

Current status of the claim is:

No action taken yet

Demand for compensation made

Lawsuit filed

How well do you understand your legal situation or issue? Please select the statement that best applies to your situation:

I understand my legal issue.

I have a couple of questions.

Gross annual income:

$25,000 or less

$25,001-$50,000

$75,001-$100,000

$100,001-$125,000

$125,000+

One Line Summary of your Case: *

Describe your Case in Detail: *

First Name *

Last Name *

City *

State or Province *

Zip / Postcode *

Phone *

Email *

Contact Preferences

Release my contact infoto Attorneys *

Yes

Notify me when attorneys respond by: *

Text Message

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What level of experience would you like your attorneyto have?

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1-5 years experience

over 16 years of experience

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