Medical Malpractice / Wrongful Death Intake Form

Below is the medical malpractice intake form we use when a new client calls with potential medical malpractice claims. If you are wondering what questions we will be asking if you call us, these are the questions we will be asking you about your potential claim. You can know exactly what to expect.

This is very detailed. You do not need to know the answer to every single question. But we do need to get the general understanding of what happened in the case and what the gist of any negligence claim could potentially be.

CALLER INFORMATION

Caller Name:____________________________________ Relationship:_____________________

Home:_____________________ Work:_____________________ Cell:_____________________

Email:_____________________

Preferred Method of Contact:____________________________________

INJURED PARTY’S INFORMATION

Injured Party’s Name:____________________________________

DOB:_____________________ Married:_____________________ Spouse Name:____________________________________

○ Minor ○ Disabled ○ Deceased Date of Death:_____________________

Address:________________________________________________________________________

City:____________________________________ State:____________________________________ Zip:__________________

Home:_____________________ Work:_____________________ Cell:_____________________

Email:____________________________________

Preferred Method of Contact:____________________________________

Name/number of someone who will be able to reach you:_____________________

MEDICAL NEGLIGENT INFORMATION

What injuries were sustained:

Date of suspected negligence:

What do you claim a doctor/provider did or did not do to cause an injury?

Who is the claim against:

What date were symptoms first noticed:

Did the injury require additional surgery:

Where:_____________________ Surgeon:_____________________ Date:_____________________

Any follow up treatment (dates and locations and treatment provided):

Current health status/treatment/permanency of injuries sustained:

Caller/Injured in possession of medical records?:

Subsequent treating doctor’s comments:

Did a treating doctor recommend any treatment that the injured declined? If so, what was recommended and why was it declined?

CALLER/INJURED INFORMATION

Injured’s health prior to injury, to include any and all illnesses and conditions the injured had prior to claimed negligence:

Injury occurred during routine, elective, emergency medical treatment?:

Did the injured miss time from work?

How long?:_____________________ Job:_____________________

SSDI:_____________________ Reason (mental or physical):_____________________

Disability Award related to this incident?:

IF DECEASED

Date of Death:_____________________ Place of Death:_____________________

Copy of Death Certificate:_____________________ Cause listed on Death Certificate:_____________________

Autopsy performed:_____________________ Where:_____________________

Copy of Autopsy Report:_____________________

Does Death Certificate state that the Autopsy report was available before cause of death was determined:

Was an estate opened:_____________________ PR:_____________________

Does Caller have a Letter of Administration:

Names and ages of all surviving children:

Prior Medical History:

• Diabetes
• Hypertension
• Vascular Disease/vein grafting/
• Heart disease/stents/open heart surgery/
• Stroke
• Hernia
• Ob/Gyn Operations
• Amputations
• Seizures
• Head Injuries
• Broken Bones
• Liver Disease
• Kidney Disease
• Eye Injury/operations/
• Bladder problems / Bladder Sling
• Gastric Bypass Surgery
• Colonoscopy
• Cancer
• Hepatitis / Any autoimmune disease/
• Gall Bladder disease/surgery
• Appendicitis
• Sepsis
• Dementia
• Pancreatitis
• Fibromyalgia
• Any mental health care/psychologist/psychiatrist

C.O.P.D.

Transplant surgery

Other operations:

Health Insurance:

Medicare:

Medicaid:

Federal Employee Insurance:

Tri Care:

ADDITIONAL NOTES OR COMMENTS

GUARDIAN/REPRESENTATIVE INFORMATION

(If applicable (i.e.: death, minor, disabled))

Guardian:_____________________ Relationship:_____________________

Address:

City:_____________________ State:_____________________ Zip: _____________________

Home:_____________________ Work:_____________________ Cell:_____________________

Email:____________________________________

Preferred Method of Contact:_____________________

INTAKE INFORMATION

Intake completed by:____________________________________ Date:_____________________

Reviewed by attorney:_____________________ Date:_____________________

○ Decline ○ Accept ○ Refer Out ○ Will Review Records ○ Opened in TM

FOR FIRM USE

How were you referred to our firm:________________________________________________________________________

Have you consulted with another attorney:_____________________

Attorney Name & Date of Consult:________________________________________________________________________

• PDF Version of another malpractice intake form

• Anyone calling with a viable malpractice claim is someone who has endured awful injuries or a terrible loss.  The the person doing the intake does not have real compassion for human suffering, that person should not be doing the intake.  
• Some of the same skill that applies to deposing a witness applies on an intake.  You cannot just read through the questions and write down the answers.  You have to follow-up on what the potential client is saying.  You can yourself and the prospective client a lot of time (and sometimes a lot of money for the lawyer) but getting out all of the relevant details in that initial call.
• The person doing the intake should be someone with a lot of experience looking at potential malpractice claims and knows, at least in general terms, what is and what is not a malpractice case.  A nurse-lawyer with 25 years of experience does the lion's share of our malpractice intakes.

• Sample malpractice contingency fee agreement
• More sample malpractice forms
• Learn more about medical negligence claims in Maryland
• Summary of Maryland law as it relates to malpractice
• Decrease chance of malpractice by getting the right doctor
• Value of malpractice cases

Our lawyers fight for medical malpractice victims. If you are a victim or you are a lawyer who has a case they may wish to refer to us with a fee split consistent with Maryland Rule 1.5, call 800-553-8082 or reach out to us online.