Medical Malpractice Case Review Form

For a free, no-obligation consultation with an experienced attorney, please submit the following questionnaire. We will respect the confidentiality of your information to the fullest extent. These form submissions are relayed to us through highly secure servers.

By completing the following questionnaire, you will be able to describe your problem, tell us who you are and how we can contact you. Note: This information is strictly confidential and will not be given to anyone outside our law firm. You must complete the identification information. We cannot respond to a person who is not properly identified. After your initial contact with our firm, you may be requested to provide additional details in order for us to properly analyze your case. However, for most cases, the following will be enough to conduct the initial review.

1. Many times, we are contacted by someone other than the person in need of help, such as a parent on behalf of the child, or a spouse on behalf of an injured spouse or by a friend. Are you submitting this form for yourself or for someone else?
For myself
For someone else

If you are submitting this form for yourself, please skip numbers 2 through 11 and go directly to number 12. If you are submitting this form on behalf of someone else (your child, your spouse, a relative or a friend), please complete items numbered 2 through 11. This information will tell us who you are and how to reach you.

2. First Name

3. Last Name

4. Number, Street & Apt.

5. City

6. State

7. Zip

8. Email

9. Day Phone

10. Night Phone

11. What is your relationship to the person who has the problem?

This section provides us with information about the person who was harmed.

12. First Name

13. Last Name

14. Age

15. Occupation

16. For how long

17. Name of current or last employer

18. City and State where last employed

19. Highest grade completed

20. Last School/College attended

21. Highest degree obtained

22. Year degree granted

23. Special training or experience in

24. Please provide a very brief general description (in 200 words or less) of your problem and what has occurred. Please do not repeat the details that you will be providing in answer to the later questions. You may wish to review the questions which follow now before providing your brief description.

25. Tell us the date you were injured or when you first learned that you had been damaged?

26. Where did it happen? Please type in the City, County and State where it happened:
City

State

County

27. Who caused the harm? Please type in the names & addresses of all the wrongdoers involved:

28. Describe the damage or injury to you as a result of the occurrence:

29. Has anyone already filed a lawsuit?
Yes
No

30. Where there any witnesses to the occurrence aside from yourself?
Yes
No

31. What is the best time to reach you by telephone?

Please provide the address and contact information below for the person who has been damaged.

32. Number, Street & Apt.

33. City

34. State

35. Zip

36. Email

37. Day Phone

38. Night Phone

Please review your answers before you submit this form.

When the information you have provided is complete, please press the Submit button below to send it to The Law Office of Steven E. North. Your information will be kept strictly confidential.

The medical malpractice injury information offered by The Law Offices of Steven E. North and contained herein, regarding New York medical malpractice injury statutes and New York medical malpractice injury claimants' rights is general in scope. No attorney client relationship with our New York medical malpractice injury attorneys is hereby formed nor is the medical malpractice injury information herein intended as formal legal advice. Please contact a New York personal medical malpractice injury lawyer regarding your specific inquiry.