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Free Case Review

Please check one or more of the boxes that apply. If the malpractice resulted in death, check the malpractice type that applies and the wrongful death box. You will then be directed to a form or forms that is/are specific for the type of alleged malpractice. Please take the time to fill out these forms in detail. It will greatly assist our reviewing physicians in determining whether or not you have a provable case of medical malpractice. These forms were carefully developed in consultation with our reviewing physicians and based on our more than 40 years of collective experience in handling these types of cases. It will also speed the process of evaluation greatly.

If you are contacting us on behalf of someone else, please provide contact information for yourself and the patient on behalf of whom you are contacting us.

General Medical Malpractice

On what date do you allege that the malpractice occurred?

Where did the alleged malpractice  occur (please give facility name, City and State)

If you are inquiring about care to someone other than yourself, who is the patient you are inquiring about? (Give their contact information and relation to you)

Please Describe in Detail what happened

Did the patient have prior medical problems, if so describe

Name of Negligent Doctor

Name of Defendant Hospital

Name(s) of Negligent Nurses

What do you allege that the doctor or nurse did wrong?

Describe the injuries in Detail. Include in your response whether the injuries are permanent or disabling

How much are the medical expenses caused by the alleged malpractice

Were any part of the medical expenses paid by Medicare or Medicaid?

Have you contacted or previously retained another attorney?  If so explain who, when, etc

Has any physician told you that your doctor was negligent?  If so who?

Do you still treat with the negligent doctor?

Who is your current treating doctor?

Birth Injury

When was your baby born?

Was the baby born alive?

What do you allege that the doctor or hospital did wrong that you think is medical malpractice?

Please provide the date of the alleged malpractice

What is the name of your OB/GYN?

Have you been receiving regular prenatal care?

Did your OB/GYN identify any potential problems with the pregnancy?

Had you undergone any ultrasounds during the prenatal period? If so were they normal?

How many weeks pregnant were you when problems developed?

How big was the baby as of the last visit to your OB/GYN BEFORE birth?

How big was the baby at birth?

Were foreceps or other tools used during the birth process?

Was the drug Pitocin used during the birth process?

What were the baby’s APGAR scores?

Was the delivery by C-Section or natural birth?

Were there any problems that you know of that were identified on the Fetal Heart Monitor Strips?

Did you have gestetational diabetes?

Did you have diabetes before this pregnancy?

Have you ever miscarried before this pregnancy? If yes, give details.

Were you on any medications during the prenatal period? If so please identify.

Was this your first pregnancy? If not, how many prior pregnancies? Any prior problems?

What are the injuries to your baby?

Have you been told that these injuries are permanent?

Retained Sponge or Instrument

What type of foreign material do you allege was improperly left inside of your body cavity?

When do you allege that a sponge or instrument was left inside your body cavity?

Identify the facility (and City and State) where you allege that this occurred

Identify the doctors and/or nurses involved in the surgery or procedure wherein the sponge or instrument was placed in your body.

What type of surgery or procedure were you undergoing when the sponge or instrument was left inside of your body cavity?

Please describe in detail the circumstances surrounding this incident.

Has the sponge or instrument been removed?

When was it removed?

When did you first discover that a sponge or instrument was left inside your body cavity?

Do you have an x-ray or other film showing the sponge or instrument inside of you?

What injuries have you sustained as a result of the sponge or instrument being left inside?

How much medical expenses have you incurred as a result of the sponge or instrument being left inside of you?

Will you suffer any permanent long–term problems as a result of this sponge or instrument being left inside of you?

Failure to Diagnose Heart Attack

What symptoms did you first experience that you believe were related to a heart attack or cardiac event?

When did you first begin to experience these symptoms?

What facility did you present to with these symptoms?

When did you first present to a healthcare facility (what time?)

Did you tell the triage nurse all of these symptoms and when they began?

If you presented to an E.R. how long did you wait to be triaged by the nurse?

How long did you wait from the time of triage until they brought you to the back?

Did the doctor order or perform an EKG?

Did he perform more than one EKG while you were there?

Did the doctor order or take any blood work from you?

Did he perform more than one set of blood work from you while you were there?

How long were you at the facility before discharge?

What discharge instructions did you get (both written and oral)?

To your knowledge was a cardiologist ever called or consulted regarding your care?

Were you admitted to the hospital for observation?

What other tests were performed while you were there?

 What treatment was given to you?

What was your diagnosis?

What damages have you suffered?

How much medical expenses have you incurred?

Failure to Diagnose Strokes

Give us a statement of what happened, with details.

What is the alleged act of malpractice?

What symptoms did you first experience that you now believe were related to a stroke or cerebral vascular accident?

When did you first start experiencing these symptoms?

What healthcare facility did you first present to?

At what time did you first present to this facility?

How long did you wait to be triaged?

How long after you spoke with the triage nurse were you taken to the back?

What symptoms were you experiencing when you went to the facility?

What tests did the facility perform? (MRI, CT Scan, others)

What diagnosis was made (what were you told?)

Was your stroke Ischemic (a blockage) or Hemorrhagic (bleeding into the brain)?

Did they draw blood and if so what results were you told about any results?

What treatment did they provide

Were you ever given the option to undergo treatment with blood clot busting drugs like TPA?

Were you discharged or admitted to the hospital?

If discharged what written and/or oral discharge instructions were you given?

If you were admitted, what treatment was provided?

What injuries have you sustained that you would not have had if you were given the correct medical treatment?

How much medical expenses have you incurred as a result of the alleged malpractice?

Do you suffer any permanent disability as a result of the stroke?

Failure to Diagnose Cancer

Give us a detailed explanation of what happened?

What act of malpractice do you allege occurred?

What are the names of the doctors, nurses or hospital which you allege committed malpractice?

What was the date that you first learned that you had cancer?

What was the date that you first went to a healthcare provider with the symptoms that later were found to be related to cancer?

What was the period of delay between you seeing a healthcare provider with symptoms and them actually diagnosing you with cancer?

What type of cancer were you diagnosed with? (squamous cell, adenocarcinoma, glioma, etc)?

What is the stage of the cancer?

Has the cancer spread (metastasized)?

Have you had your lymph nodes tested or taken out to see if the cancer has spread?

Where was the site of your primary cancer (lung, brain, breast, cervical, uterine, pancreas, colon, other)?

What treatment have you undergone to treat the cancer?

What does the doctor tell you about your prognosis for a full recovery?

Did you ever have any tests prior to learning that you had cancer that you believe should have caught the cancer diagnosis (like a colonoscopy, mammogram or other test)?

How old are you?

Prior to learning that you had cancer, had your primary care doctor or health care provider ever offered you any type of cancer screening tests?

How much in medical expenses have you incurred as a result of the failure to timely diagnose your cancer?

Were any part of the medical expenses paid by medicare or Medicaid?  If not, do you have private medical insurance?

Medication Error

Describe in detail what happened

Were you given the wrong medication or were you given an improper dosage of the correct medication?

If given the wrong medication, what is the medication that you allege was given to you in error?

What medication were you supposed to get?

If given the wrong dosage, what was the correct dosage and what was the dosage that you were given?

What was the name of the medication that you received the wrong dosage?

What injuries did you suffer from being given either the wrong medication or the wrong dosage?

Who gave you the wrong medication or dosage?

Do you know if the doctor ordered the correct medication or dosage and the person (nurse) who gave it gave the wrong one?

Was the wrong medication or dosage given by a pharmacy?  If so, which one?

Do you have copies of the prescription written by your doctor?

How did you discover that you were the victim of a medication error?

When did you discover this?

What medical expenses have you incurred as a result of this medication error

Respiratory or Pulmonary Error

Describe in detail what occurred?

Did you suffer from ARDS or any other pulmonary lung disease?

Did the error occur during an attempt at intubation?

Was a pulmonologist involved in your care as either a treating physician or consultant?

Were you on any monitoring equipment at the time of the error?

Were you hooked up to a pulse oximetry device at the time of the error?

What do you believe was the act of malpractice involved in your care?

Failure to Diagnose Other Condition

Describe in detail what happened.

What condition do you allege that the health care provider failed to diagnose on a timely basis?

When do you believe that the health care provider should have diagnosed this condition?

How long was the delay between when you believe the condition was diagnosable and when it was actually diagnosed?

What damages or injury did you suffer as a result of the failure to diagnose the condition?

What symptoms were you having that you believe should have lead to the proper or timely diagnosis?

Was the condition ever correctly diagnosed? If so, when and by whom?

Has any doctor told you that the condition should have been diagnosed based on your symptoms? If so, who?

Did you undergo prior tests which you believe should have led to a diagnosis of this condition?

Is your prognosis for future recovery now limited because the condition was not diagnosed sooner? If so, how?

Surgical Mistake

Describe in detail what happened.

What type of surgery or procedure was being undertaken when the mistake occurred?

Did you sign a written consent form for the surgery?

Was the surgery or procedure being performed on an emergent basis?

What pre surgery instructions were given to you regarding preparation for the surgery? (no foods or liquids before surgery, etc)

List other medical problems that you had prior to surgery (diabetes, heart  failure, etc)

Did you get clearance from another doctor prior to undergoing surgery? (like a cardiologist)

What medications were you on prior to surgery?

Were any of those medications stopped before surgery?

When were any of those medications resumed after surgery?

Did you develop any post surgical complications?

Were you transferred from the recovery room to the ICU or post surgical room with a monitor being placed on you to monitor your vitals and breathing?

How long after surgery were you extubated?

Prior to surgery, did you have any problems with your blood clotting?

Do you alleged that any instrument or piece of equipment malfunctioned or was operated wrong during the surgery?  If so, please explain.

Did any healthcare provider tell you that a mistake or error occurred during the surgery?

Vascular or Blood Vessel Injury

Describe in detail what happened.

What type of procedure were you undergoing when the injury occurred?

What blood vessel or artery was involved or injured?

How did this injury occur?

Was the vessel or artery repaired?

Did the repair happen in a second or different surgery?

What damages have you suffered as a result of this mistake or injury?

Are any of your injuries permanent or disabling?

Was the injury caused by an instrument or piece of medical equipment?

If an artery or blood vessel was injured do you know if the vessel was completely severed or was the vessel or artery compressed without being cut in two pieces?

Radiology Misinterpretation

Describe in detail what happened.

What type of diagnostic test do you allege was misread or misinterpreted

Were previous tests (MRI’s, CT’s, x-rays, mammograms) taken on the same area of the body?

Do you have copies of the films you believe were misread?

Do you have copies of the previous films on the same area of your body for comparison?

Was the doctor who you believe misread the films a radiologist?  If not, what type of doctor was he?

Do you know if the films which you believe were misread ever overread by a radiologist?

Did any other doctor have a different interpretation of the films from the doctor you believe misread them?

What was the time frame between the misread of the films and the correct reading being made?

What do you allege was the injury or damages you suffered as a result of the misread of the films?

Infection

Describe in detail what happened.

What type of infection did you suffer from?

When did symptoms of this infection first appear?

Since infection can be a known complication, what do you allege was the malpractice associated with your infection?

Do you know if the infection site was swabbed or aspirated so that tests could be run to determine the type of germ causing the infection?

Were you ever told what type of germ was involved (staph, strep, etc)?

How long after the symptoms first appeared were you given antibiotics?

Were the type of antibiotics ever changed?

Do you know if a consultation from an infectious disease doctor was ever obtained?

What damages did you suffer as a result of this infection?

Do you have any permanent problems or disability as a result of the infection?

If you believe that your infection should have been caught and/or treated sooner, what is the period of delay between when it was caught and treated and when it should have been caught and treated?

Was your blood work (a complete blood count) being monitored on a regular basis at the time symptoms of your infection first appeared?

Did the infection cause dead tissue that had to be cut out in surgery?

Did you undergo I.V. antibiotic treatment once the infection was diagnosed?

Brain Injury

Describe in detail what happened.

What type of brain injury did you suffer?

What do you allege was the malpractice that caused or contributed to your brain injury?

How was your brain injury treated?

What damages have you suffered as a result of your brain injury?

Do you have any permanent disability as a result of your brain injury?

Had you had any prior history of seizures or other brain related problems?

Were you on any medications for seizures or brain related problems?

Do you have any other medical conditions which you believe may have caused or contributed to the brain problem?

Did the brain injury occur during a surgery or procedure? If so, what type?

Spinal Injury

Describe in detail what happened?

What type of spinal injury did you incur?

What do you allege was the malpractice associated with your spinal injury?

What level of your spine was injured?

Did the injury occur during a surgery?

Is this related to a failed prior back surgery?

Has any subsequent physician told you that any prior surgery was performed incorrectly?

Does this case involve an operation at the wrong level of your spine?

Does this case involve any problems with hardware (plates, screws, cages) which failed or were not properly placed during surgery?

What injuries did you suffer from the alleged malpractice?

Are your injuries permanent or disabling?

If this involved a back surgery was the back surgery elective?

Had you ever had prior back surgery?

Was the doctor who performed the back surgery an orthopedic surgeon or a neurosurgeon?

Have you undergone any surgeries to correct the alleged malpractice?

Dialysis Mistake

Describe in detail what happened?

How long have you been on dialysis?

What access point is used for your dialysis (Arm, neck, etc)

Who is the Nephrologist (kidney doctor) who is in charge of monitoring your care?

What facility do you go to for dialysis?

How often is your blood work performed/monitored?

Are you on erythropoietin (EPO) or another drug that helps rebuild red blood cells?

Do you have any allergies to the dialyzer filter? 

Have you had any allergic reactions in the past during or after dialysis?

Do you have any other known allergies?

Have you had prior problems with clogging of the dialysis port?

Have you ever missed your dialysis appointment?

Has a doctor ever withheld dialysis or told you to it was ok to miss a dialysis session?

Did you have any level of kidney function at the time of the incident?

What injury or damages have you suffered as a result of the dialysis error?

Do you have a permanent disability as a result of this error?

Have you ever been anemic before, during or after dialysis?  If so, do you have a copy of your lab work?

Do you allege that the dialysis error was the fault of the dialysis clinic or your treating nephrologist?

Wrongful Death

Was an autopsy performed in this matter?

If so, do you have a copy of the autopsy report?

What does the autopsy report state as the cause of death?

Who performed the autopsy and where was it performed?

Is there a surviving spouse or children of the deceased?  If so, please provide their names, addresses and contact information.

Are any of the surviving children minors?

If there are surviving children of the deceased, were any of the children adopted?

If there are surviving children of the deceased, was the deceased listed as the natural father on the surviving children’s birth certificate?

If the deceased is not listed as the father of the surviving children on their birth certificate, did the deceased ever formally or informally acknowledge that those were his children?

How much in wages did the deceased earn annually?

To whom was the deceased providing support at the time of the death?

Has a succession or other legal proceeding been open since the death?

Did the deceased leave a will?

If so, do you have a copy of the will?

Pharmaceutical and Drug Cases

Describe in detail what happened.

What is the drug that you believe caused your problem?

Are you aware of any class action lawsuits involving this drug?

Are you aware of any recalls of this drug?

Has any physician told you that the drug in question caused you to suffer injury?

What injuries have you suffered as a result of this drug?

How much in medical expenses have you incurred due to this drug and the injuries it caused?

Are your injuries permanent or disabling?

What is the problem with this drug that you believe caused your injuries?

Do you know whether your physician was using this drug for an "off label" treatment? (a treatment for which the drug was not approved by the FDA).

When did you start taking the drug?

When did you start experiencing symptoms from taking the drug?

How long were you on the drug?

Was there any monitoring that your physician did regarding the level of drug he was giving to you over time?

Defective Medical Product

Describe in detail what happened.

What is the medical device that you believe was defective?

Who was the product manufacturer?

What was the product model or serial number?

Who has the product now? Did the doctor or hospital save it for inspection?

Why do you think the product was defective? Did any health care provider tell you it was defective?

Are you aware of any recalls for this product?

Do you know if the health care provider operated or used the device properly?

What damages/injuries have you incurred as a result of the defective product?

Is your treating physician willing to discuss this defective product with an attorney?

How much in medical expenses have you incurred as a result of this defective product?

Are your injuries permanent or disabling?

Does your doctor have the product manual or product inserts on the defective product?

Do you know if any changes or modifications were made to the defective product (either before or after it injured you)?

Skeletal Injuries (Broken Bones)

Describe in detail what happened.

What injury did you sustain?

What bone was injured or broken?

How did it happen?

What is the alleged malpractice associated with this injury?

Were you being treated by an orthopedic surgeon?

Have you undergone surgery?

What damages have you sustained as a result of the alleged malpractice?

How much in medical expenses have you incurred as a result of the alleged malpractice?

Has any physician told you that your doctor committed malpractice?

Do you have any bone deformity or permanent disability as a result of this malpractice?

Has another surgeon undertaken corrective action or surgery to correct the malpractice?

What is your prognosis for future recovery?

Have you had any bone infection or other complications from the bone injury?

Eye Cases

Please describe in detail what happened.

What was your (uncorrected with glasses or contacts) visual acuity prior to the alleged malpractice.

What is your uncorrected visual acuity after the malpractice?

What do you allege that your eye doctor did or failed to do that is malpractice?

Have you had eye surgery to correct the malpractice?

What eye disease was your eye doctor treating at the time the malpractice occurred?

Has any other eye doctor told you that the first doctor committed malpractice?

Does this case involve a detached retina?

What prior diseases did you have that caused or contributed to eye problems? (diabetes, macular degeneration, cataracts, etc).

What damages have you suffered as a result of the alleged malpractice?

What is your prognosis for recovery of your vision following the malpractice?

Dental Malpractice

Dental malpractice cases are rarely worth pursuing. This is because another dentist can fix virtually any problem caused by the negligent dentist. This means that the damages are low. Since malpractice cases require expert witnesses who are very expensive, the damages in a case must be very significant (over 100k) to justify pursuing a case. With that in mind, there are some limited circumstances in which these cases are worth pursuing.

Describe in detail what happened.

How much in medical expenses have you incurred as a result of the dental malpractice?

What damages have you sustained as a result of the alleged malpractice?

What do you allege your dentist did that constitutes malpractice?

Are any injuries that you suffered permanent or disabling?

Did the dental malpractice result in a death?

Did the dental malpractice result in permanent nerve damage to the face or jaw?

Did the dental malpractice cause a serious medication error?

Has another dentist or orthodontist fixed the problem?

* First Name

* Last Name

Patient's Name (if different from yours)

Street Address

City

State

Zip Code

Home Phone Number (including area code)

Cell Phone Number (including area code)

* Email Address

Date That Alleged Malpractice Occurred

Date You Found Out That Malpractice Occurred

Do you have a copy of your medical records

Name of negligent physician

Name of negligent nurse

Name of hospital or clinic where alleged malpractice occurred (including City and State)

To your knowledge, has the doctor or nurse that you allege was negligent had any disciplinary action taken against them or their license at any time?

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