Your Name:
Address:
Email address:
Phone number:
Summary of issue (in 10 or less words):
Date of birth:
Do you have a spouse who lives with you? YesNo
When did you find out about the alleged negligence by your dentist?
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? YesNo
What is the name and address of the dental group?
Are you still treating with the suspected negligent dentist? YesNo
Do you have a copy of your dental records, including x-rays? YesNo
Is your dentist a specialist? YesNo
What is your dentist's area of specialty?
Have you lost earnings or income as a result of your injury? YesNo
Please estimate your loss of earnings or income for which you have proof:
What made you realize that you were the victim of your dentist’s alleged negligence?
How did the alleged malpractice of the dentist(s) injure you?
Did another dentist/health care provider advise you that negligence may have been present in your care and treatment? YesNo
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?
Who referred you to us? Click to selectAnother attorneyAnother dentistA search engine
What is the attorney's name?
What is the dentist's name?
Which search engine was it?
Other Notes and Comments: "I understand that the attorneys of 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."
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