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The Bernstein Approach
 

Medical Malpractice

Step 2 of 3

Please tell us more about the injured person:

Injured person's first name: required field
Injured person's last name: required field
Address:
City:
State:
Zip:
Area code & phone number:
 - -
  Home Work Mobile
Age:
Gender: Male Female
______________________________

Please tell us about the injury:
Date of injury:
Doctor/hospital - Name:
Doctor/hospital location - City:
Doctor/hospital location - State:
What is the injury that you feel was a result of malpractice?
What was the mistake made by the doctor or hospital?
What is the current status of the injury?
Date you discovered malpractice:
______________________________
Did you previously consult another attorney about this injury?
Yes No
Is another attorney currently involved?
Yes No

required field = Required Why?

 
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