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06th July 2008

Medical Negligence Questionnaire

If you have suffered a medical accident where you might be able to claim compensation and would like a no obligation FREE assessment please complete this questionnaire and we will contact you.

Your details:

Title (Mr/Mrs/Miss)
Initials
Surname
Address
Daytime Telephone
Evening Telephone
Fax
Email
Date of Negligence

Details of whom you think were at fault:

GP treating you (if applicable)
Initals
Surname
Date of 1st consultation
Address
Telephone
Fax
Email

Dentist treating you (if applicable):

GP treating you (if applicable)
Initals
Surname
Date of 1st consultation
Address
Telephone
Fax
Email

Hospital treating you (if applicable):

Name
Address
Telephone
Fax

Please describe what you were being treated for?

Please describe why you feel they were at fault?

What resulted from your treatment?

Any other details you feel important?