Medical Negligence Case Evaluation

We have found that it is much more effective to collect this initial information via an online questionnaire rather than from a phone conversation because it allows you to gather and organize important facts such as doctor names, facility names, dates, diagnosis and other details.

In order to evaluate your potential medical malpractice claim we need some specific medical history and treatment information. This information is essential to the evaluation process. We cannot evaluate your claim without your answers to these questions.

Please fill out medical malpractice questionnaire below.
We will contact you regarding any additional information that may be required by our case evaluation team--such as if specific medical records are required.
The case investigation team will review the information and contact accordingly.

All Answers Are Strictly Confidential

The answers you give on this form are for our use only in the evaluation of a potential medical malpractice claim. Although some questions may ask for personal information, all questions have a legitimate purpose. The thorough evaluation of your claim depends upon the accuracy and completeness of your answers.

Medical Malpractice Case Evaluation Questionnaire

The thorough evaluation of your claim depends upon the accuracy and completeness of your answers. All answers are confidential.

Please check ONLY one.

A Davis Law Group case investigator asked me to fill out this form.

I have not yet communicated with Davis Law Group. This is my first contact with the firm.

Name of Medical Malpractice Victim *

Victim's Date of Birth *

What is your relationship to the victim? Self, spouse, parent, child, friend? *

Your Name *

Your Address *

Your City *

Your State *

Your Zip *

Your Country *

Your Phone Number *

Your Email Address *

Please identify the name of the treating physician(s), medical provider(s),and/or hospital(s) that you feel are responsible for your claim of malpractice: *

Malpractice Date *

Reason for Treatment

Please describe the care and treatment that you feel was improper, who provided it, and what it is that your doctor/ hospital did or failed to do in treating you: *

INJURIES: Please list all injuries and disabilities you have sustained because of the above incident. If you are able, set forth whether you believe that the injuries will be permanent. *

Do you have any appointments scheduled for future medical care? Yes/No *

If you answered 'yes' to the question above, please provide detail as to the date, provider, and purpose of the future treatment:

Have you ever been treated for a similar injury or condition in the past? If yes, please explain: *

As a result of the medical malpractice that may potentially form the basis of a legal claim, have you been (check all that apply):

Totally disabled

Partially disabled

Confined to hospitals

Confined to house

Confined to bed

If you checked any boxes in the question above, please give details as to the amount of time of each.

Have you gotten a 2nd opinion? In other words, has any health care provider told you that there was negligence in your care? And if so, who? *

I understand that the answers given on this form are only for the evaluation of a potential medical malpractice claim. Filling out this form does not create an attorney-client relationship between you and Davis Law Group. I understand that Davis Law Group will review the information and evaluate the potential claim but may or may not agree to represent me in this matter.

Yes, I understand *