2. Home Address:

Zip Code:

*Email Address:

3. Business address:

Employer:

II. MEDICAL/DENTAL NEGLIGENCE

6. Names, addresses, dates of treatment, and treatment performed by all physicians or dentists who may have been negligent: PROVIDE FULL NAMES AND ADDRESSES

7. Brief description of negligence:

8. Date you first suspected negligence:

How?

9. Date you first knew of negligence:

How?

10. If another health care provider advised you that negligence was or may have been committed, state: Name and address of dentist who advised you:

When advice was given:

What was said:

III. INJURIES AND CORRECTIVE DENTAL/MEDICAL TREATMENT

11. List every illness or injury, even if slight, which you believe was caused or made worse by negligence:

12. Names, addresses, and dates of treatment of dentists or physicians who have treated or will treat you for negligently caused injuries:

13. List treatment performed or recommended by dentists or physicians named in number 12 above. Indicate present status of treatment, i.e. whether ongoing, completed, or planned, and costs of treatment:

14. List all other dental or expenses incurred as a result of the negligence (include drug prescriptions):

V. WAGE LOSS

15. Are you claiming past and/or future lost wages?   YesNo

(If yes, answer the questions below. If no, skip to Section VI.)

18. Amount of lost wages and how you calculated the loss:

19. Any other lost wages due to use of sick leave benefits or other benefits, or time made up due to dental visits, and how you calculated the loss:

I certify the above information to be true and complete to the best of my knowledge and belief in order to assist the attorney in evaluating my case.

Dated:

Signed: