Questionnaire - Levy Law Firm

About You: (all these fields must be entered)

Your Name: *

Address: *

Email address: *

Phone number: *

Summary of issue (in 300 words or fewer): *

Date of birth: *

Do you have a spouse who lives with you?

Yes
No

About Your Case

Date of injury? *

What was the specific dental procedure or dental treatment involved?

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

What is the name and address of the dental group?

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

Is your dentist a specialist?

Yes
No

What is your dentist's area of specialty?

Have you incurred out-of-pocket monetary expenses / losses?

Yes
No

Please estimate your out-of-pocket monetary expenses / losses for which you have proof:

When did you find out about the alleged negligence by your dentist? *

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? *

What best describes your dental injury? *

Did another dentist/health care provider advise you that negligence may have been present in your care and treatment?

Yes
No

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?

What is the dentist's name?

What is the attorney's name?

Which search engine was it?

Comments

Other Notes and Comments:

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"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." *

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.

Date / Time

Date

Time