MEDICAL CASE EVALUATION FORM

Name

First Name

Last Name

Phone

(###)

###

####

If someone referred your to me, who can I thank?

Name of Doctor / Hospital (if known)

Date of procedure / treatment (best estimate if unknown)

YYYY

General type of treatment (e.g. surgery, delayed diagnosis, medication error, etc. )

Briefly describe what you think the Doctor / Hospital did wrong

Briefly describe your injuries that resulted and, if applicable, the treatment needed to fix

Date you first learned of your injuries (best estimate if unknown)

YYYY

What Is Your Primary Purpose For Seeking Legal Assistance?

Obtain a refund

File a lawsuit for damages

File a complaint with the Medical Board

Is there anything else you want Scott to know about your claim?

Acknowledgement

The information you are submitting is privileged and confidential, however, you understand and acknowledge it does not create an attorney-client relationship with Scott M. Kuboff, Esq. and Lowe Scott Fisher Co. LPA