Medical Negligence Questionnaire

Medical Negligence Questionnaire

Thank you for contacting us regarding your potential medical negligence claim. Our firm’s procedure is as follows:

You’ll find below some initial important questions that allow us to preliminarily evaluate whether we can assist you on your claim. Medical negligence cases are typically extremely technical and complex, as well often there are conflicts with our ability to sue certain providers (e.g., treating physician of our staff, client or other relationship). Please note, however, that everything submitted to us for a potential client is privileged—it cannot be disclosed (i.e., it’s confidential).

To have a viable, successful claim, an attorney must prove negligence, causation, and damages, and Nevada law most often requires at least one medical expert practicing in the same area as those involved to support the case with opinions under oath. For us to determine whether hiring an attorney and proceeding with a claim is in your best interest with our firm, we need to ask about what occurred, why you believe there was negligent conduct, and the extent of the damages caused by the potential medical negligence. Please respond to the questions below. Feel free to attach any supporting records, photographs or other evidence you think may be helpful for our review. If dropping anything off at our office, we cannot accept any original materials, rather only copies are to be provided.

Once received, one of our attorneys will review your information. When contacted, either the attorney or assistant will advise you of the decision or whether more information is requested. Please note that an attorney-client relationship is NOT formed unless and until there is an executed fee agreement between our firm and you. In other words, we do NOT represent you unless and until we take your case by you and us signing a fee agreement. Further, while we are reviewing your information to evaluate and investigate your potential claim, we will NOT be tracking or protecting any limitations deadline like the statute of limitations, which may be as little as one (1) year from injury or a related death. Only by filing a lawsuit with the proper materials can you protect the statute of limitations.

If you do not hear back from us within 14 days, you can consider this a rejection of your case. While our goal is to respond to every inquiry within 14 days, circumstances may unfortunately prevent us from doing so. Therefore, you need to protect your own statute of limitations until an attorney takes your case. So, while we are reviewing your potential case, you should be contacting other attorneys and asking them to do the same.

Please confirm that you have read our firm’s procedure for medical negligence claims by checking the box below. Once you have done so, you will be directed to the Questionnaire. Thank you for your time and inquiry.

I have read and understood the above information*

Questionnaire Form

Fields marked with an asterisk (*) are required.

Are you contacting us regarding an injury or a death? (Please specify which one)*
Please make a selection.
First name *
Please enter your first name.
Last name *
Please enter your last name.
Address *
Please enter your address.
City *
Please enter your City.
State *
Please enter your state.
ZipCode *
Please enter your zipcode.
Phone*
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This isn't a valid phone number.
Email*
Please enter your email address.

This isn't a valid email address.
Today's Date *
Birth Month
Please make a selection.
Day of Birth
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Birth Year
Please make a selection.

Who is the injured person? *
Please tell us the injured person
If you’re not the injured person, who is and what is their relationship to you?
What is the Injured person’s date of birth? *
Please tell us the injured persons date of birth
Did the injuries result in death?
If a death occurred, was there a coroner’s investigation or autopsy?
If the person died, are you suspecting negligence caused the death?
How did you hear about our law firm? (List all please.) *
Please enter how you heard about our firm
Who are the potential defendants (i.e., negligent parties)?*
Please enter a message.

(We need the names to determine whether we may have a conflict of interest. For example, we cannot sue a doctor who is the treating physician for one of our existing clients.)
When did the injury occur that you believe was the result of medical negligence? *
If the injuries resulted in a death, what is the date of death?
In summary, what happened? *
Please enter a message.
When did you or the injured person first suspect negligence?*
Why do you believe there was a medical negligence? *
Please enter your answer.
What evidence do you have to support your belief that there was medical negligence? *
Please enter a message.

(For example, do you have a medical opinion from a doctor, nurse or other; do you have an admission of guilt from a medical provider; a finding of negligence from medical board or internal investigation; and/or records or photographs.)

DAMAGES – PROVIDE YOUR ESTIMATES AS TO THE FOLLOWING DAMAGES YOU BELIEVE ARE RELATED TO THE MEDICAL NEGLIGENCE.

Estimate of total past medical bills related to medical care as a result of the negligence:*
Please enter your answer.

(Not your portion or what the insurance paid, but the total bills charged)
Estimate of future medical bills for ongoing treatment needed as a result of the medical negligence:*
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Estimate of related lost income (or financial support if a death):*
Please enter your answer.
Related past pain, suffering and disfigurement?*
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Related future pain, suffering and disfigurement?*
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INSURANCE

What health insurance has paid or do you expect will pay the medical expenses?*
Please enter your answer.

(Please specify if Medicare, Medicaid, or other.)
If this is a wrongful death case, was the decedent on Medicaid?