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Medical Malpractice Form

Personal Information

Fields marked with an * are required for the form to work.

*Name: Title: 
Address:  City:  State:  Zip: 
Mailing address (If different):  City:  State:  Zip: 
Date of Birth (mm/dd/yy): 

Phone Numbers (Include Area Code)

Home Phone:  Work Phone:  Cell Phone: 
*E-mail address? 

Where do you work? 
What is your current Job title? 
Were you in the course of employment at the time of the accident?  Yes No
Does the place of your employment carry workers comp?  Yes No
Do you expect to miss work because of your injuries?  Yes No
What are your duties at work?


How many dependents do you have? 

If you are a minor:

Who is your natural mother? 
Address:   City:   State:   Zip: 
Who is your natural father? 
Address:   City:   State:   Zip: 
What is your natural parents' marital status?:
Married Separated Divorced One Deceased Both Deceased

Have you had other injuries prior to this injury?: Yes No
Who is your insurance carrier?: 
Have you contacted your insurance company?:  Yes No
What is the name of your adjuster?: 
Address:   City:   State:   Zip: 
Phone Number: 
Claim Number: 

Accident Information

Please Describe the incident:

Please Describe your injuries:
Please check to make sure that all information is correct before submittal!
Completion of this form is purely for purposes of evaluation. No representation will be undertaken unless a written fee agreement, statement of client's rights and other documents are fully executed:

 

Office Location

1404 Dean Street
Suite 200
Fort Myers, FL 33901

Phone: 239-334-8850
Fax: 239-334-1963
Toll Free: 866-822-4273