Questionnaire

Please fill out the following form to allow us to evaluate your case.

About You: (all these fields must be entered)

Your name:
Address:
Date of birth:
Email address:
Phone number:

About Your Case

Name, address and phone of the suspected negligent health care provider:
Date of first visit:
Date of last visit:
Is your dentist part of a dental group? Yes
No
If yes, name and address of the dental group?
Is your dentist a specialist? Yes
No
If yes, what is your dentist's area of specialty?
Are you still treating with the suspected negligent dentist? Yes
No
Do you have a copy of your dental records, including x-rays? Yes
No
Have you lost earnings or income as a result of your injury? Yes
No
If yes, please estimate your loss of earnings or income for which you have proof.
When did you find out about the alleged negligence by your dentist?
Why your suspicion arose at that time (what did they do wrong)?
How did the alleged malpractice of defendant(s) injure you?
Did another dentist/health care provider advise you that negligence may have been present in your care and treatment? Yes
No
If you answered "Yes" who told you this? (Name, address, and phone)
What were you told?
What subsequent/remedial treatment was rendered/recommended (if any)?
Estimated cost of remedial care:
What is the present status of your remedial treatment?

Comments

Who referred you to us?
Another attorney (who)?
Another dentist (who)?
A search engine (which)?

Other Notes and Comments?

"I understand that the attorneys of www.dentalmal.com (LEVY LAW FIRM) have not accepted any professional responsibility, are not my attorneys, and they do not represent me in this matter until such time as a written retainer agreement has been entered into and executed by client and counsel."

You must agree to the above statement by checking this box.

By submitting below, I certify the information herein to be true and complete to the best of my knowledge and belief.