(831) 427-9519

©2019 by Dental Malpractice California. Developed by Spierings Communications

Client Information Report

1. GENERAL INFORMATION

2. MEDICAL/DENTAL NEGLIGENCE

3. INJURIES AND CORRECTIVE DENTAL/MEDICAL TREATMENT

4. WAGE LOSS

Are you claiming past and/or future lost wages?

(If Yes, answer the questions below. If No, skip to Signature and Submit

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.

Disclaimer: The information contained in this web site is intended to convey general information. It should not be construed as legal