Contact Information:

Please complete all of the items that apply. We will review your information and respond promptly.

Name: 

Address: 

Phone:   123-456-7890

Email:   email@provider.xxx

When is it best for us to contact you? 

How would you prefer to be contacted?  Select One Phone Email

Information About the Person with Injury/Condition

Name: 

Date of Birth/Age: 

What is your relationship to the injured?  Select One Parent Sibling Grandparent Spouse Legal Guardian Other

Has a medical diagnosis been made?  Yes  No

If yes, please explain:

If a medical diagnosis has been made, how old was the individual at the time of diagnosis? 

Additional Information

Have you previously sought legal assistance regarding a possible medical malpractice claim?  Yes  No

In what State are you located?  AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SD SC TN TX UT VT NI VA WA WV WI WY

In what State did the Injury occur?  AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SD SC TN TX UT VT NI VA WA WV WI WY

In the box below, please describe your case and tell us what you think went wrong.

If you would like to contact us directly, please call or E-mail:

(952) 941-4005

800-947-2176 Toll Free

medmal@hjlawfirm.com

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