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201 E. Kennedy Blvd. Suite 1475 Tampa, FL 33602
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Medical Malpractice Case Evaluation

Please answer as many of the following questions as you can.

Name:
Address:
City:
State:
Zip Code:
Email Address:
Phone Number:
What date did the medical care at issue begin?
Does your claim for medical malpractice extend back prior to two years from today’s date?

 Yes No
Were you the victim of an improper performance of a surgical procedure or techniques?

 Yes No
Were you the victim of a failure to diagnose a disease, cancer, or other illness?

 Yes No
Were you improperly prescribed medication that caused you physical injury?

 Yes No
List the doctor(s) and/or health care professional(s) you believe committed malpractice:
Were they assigned to you by a hospital?

 Yes No
Which hospital did you go to? When?
Did you have a pre-existing condition prior to commencing the medical care at issue?
Did anyone discuss the risks of the treatment, procedures, or medication at issue with you initially?

 Yes No
Did you sign anything acknowledging that you were aware of the risks of injury initially?

 Yes No
Did you sign an arbitration agreement prior to beginning the medical care at issue?

 Yes No
Why did you go to the doctor/hospital originally?
What treatment did you receive? What were the results of that treatment?
Please describe how the medical negligence resulted in your injury:
What is the current status of that condition?
What should the doctor/medical professional have done to avoid causing your condition?
Are you currently under a physician’s care? For what?
Has another medical care professional told you that your current condition resulted from negligence or malpractice?

Yes No
If so, who? When?
What is your diagnosis? Prognosis?
Has anyone apologized for the results of your care?
 
DISCLAIMER: Sending an email through this form will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. Please do not send sensitive or confidential information via this email form. Email sent via the Internet might be intercepted and read by third parties.
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Address: Fifth Third Center   201 E. Kennedy Blvd, Suite 1475   Tampa, FL 33602   Toll Free: 877-888-JURY Phone: 813-223-7799