Get Medical Malpractice Intake Form

Completing the Medical Malpractice Intake Form is an essential step in seeking legal assistance for medical malpractice cases. This guide provides a comprehensive, step-by-step approach to filling out the form accurately and efficiently, ensuring that your information is submitted correctly.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the Medical Malpractice Intake Form and open it for editing.
2. In the 'Client Information' section, provide your full name, date of birth, and social security number. Fill in your current address and the duration you have lived at that address. Include your home, work, and cell phone numbers, and provide your email address. If you have any former or maiden names, list those as well.
3. In the 'Injury Information' section, indicate the date of the injury and describe the incident, including any potential malpractice involved. Make sure to list all injuries sustained and name the physicians, hospitals, or other parties you believe may be responsible.
4. Record your health insurance details, including the name and phone number. Then, list all medical professionals who have treated you for this injury, including their names, phone numbers, and addresses.
5. If you have experienced similar injuries or illnesses in the past, describe these along with the dates of occurrence.
6. Provide your employment information, including your current employer, job position or title, and the employer's address and phone number. Indicate how long you have been with the employer and your gross monthly income. State if you have faced any lost wages due to the injury and specify the duration.
7. List your marital status and current prescription medications, including dosages and the names of prescribing physicians. Also, list any over-the-counter medications you are currently taking.
8. Detail any previous prescription medications taken, including their dosages and the names of prescribing physicians.
9. Answer questions regarding your ability to perform daily living activities and any impact your injuries have had on your hobbies or interests.
10. Indicate if you have a history of treatment for chemical dependency, psychiatric or psychological treatment, or any criminal record.
11. Lastly, if you have ever made previous claims for personal injuries, medical malpractice, workers' compensation, or social security disability, provide explanations for those cases.
12. Review all sections for accuracy and completeness. Once finished, you can save your changes, download, print, or share the form as needed.

Ensure you have all necessary details at hand and complete your Medical Malpractice Intake Form online today.