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MEDICAL-MALPRACTICE-LAW.com IS OPERATED BY: Richard M. Callahan, Esquire 2 Pierro Terrace Swampscott, Massachusetts, 01907 (866) 529-8373
If you or someone you know has been injured as a result of medical malpractice, you may be entitled to monetary compensation. For a free evaluation of your medical malpractice claim completely fill out the form below. Once you submit your information below, your free consultation form will be sent to a lawyer reviewing medical malpractice claims, for evaluation. That lawyer will review your form in accordance with the site terms and conditions and may contact you discuss your rights.
Free Contact a Lawyer Consultation
Injured Person Information:
Date of Birth / Age:
(ex. mm/dd/yyyy or 54)
Were you injured?
Yes No
If not, who are you
inquiring on behalf of?
If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?
Is the person deceased?
Yes No
If deceased, what is the cause of death
as stated on the death certificate:
Date of Death:
(ex. mm/dd/yyyy)
Was an autopsy performed?
Yes No
If not deceased, does the
injury prevent you or the
victim from working?
Yes No
If yes, when did you/victim stop working?
What is the approximate lost wages
due to the injury?
Accident / Injury Information:
Name of Doctor:
Date of malpractice:
*
City where malpractice occured:
*
State where malpractice occured:
*
What type of procedure, surgery or treatment
was performed?
Why do you believe malpractice occurred?
Describe injury resulting from malpractice:
Name and address of Doctor, Hospital, Nursing
Home or Healthcare facility:
Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:
Please explain the full extent of the victims injuries:
Comments / Additional Information
Is there anything else that would assist us in
understanding the facts of your case?
To Better Serve You:
Please tell us how you found us? If "other" please specify.
Please specify how you found us (if other than above):
If you found us using a search engine,
please tell us which search engine?
Please tell us exactly what terms you typed into the
search engine to find us? (i.e. Personal Injury Lawyers)
I understand that by filling out this free consultation form I am not forming an attorney client relationship. I understand that I may only retain an attorney by entering into a fee agreement and that by submitting this form I am not entering into a fee agreement. I understand that not all submissions may receive a response.
Yes
No
I agree that the above does not constitute a request for legal advice. I agree that any information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. I agree that if this matter requires advice regarding my home state, local counsel may be contacted for referral of this matter. I understand that email is not secure and thus I am not forming a confidential relationship.
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