Medical Negligence Questionnaire - Medical Negligence solicitors in Darlington, Spennymoor, County Durham and Northallerton

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Medical Negligence Questionnaire:

Please would you read through the following questions carefully and answer them as best as you can. If you have any difficulty then please ask for help from Mr. Dorian Williams or Mr Kevin Campbell. Once your questionnaire is complete, click the "send my information" button to send us your completed questionnaire.


Personal Information:

Name:
Address:

Town:
County:
Postcode:
Daytime Telephone:
Evening Telephone:
Email:
Date of Birth:
N.I. Number:

Your Claim:

Please give details of the nature of your claim:
The name and address of the Hospital or Health Trust:
The name of your treating Doctor or Surgeon:
The name and address of your GP:
The date of your operation or treatment:
Did you sign a consent form for treatment?
What treatment did you consent to?
What risks were explained to you before you received treatment?
What date were the risks explained to you?
Who explained the risks to you?
What date did you learn of negligence / errors?
Who explained that there had been a failure in treatment?
Where possible give dates of visits to your doctor / hospital and details of any treatment given on each date:
If you have made complaints concerning treatments, please give details of whom to and when:
Give details of any diagnosis given by your treating doctor:
Give details of actual treatment you received:
Give details of errors or omissions in your treatment:
If you have yet to make a full recovery, please give details of your symptoms:
Have you suffered from similar conditions / symptoms prior to negligent treatment?
Your Occupation:
If you have received private medical treatment, please give details of treatment and full address of medical facility:
If you require further treatment, please give details:
Please detail fees / expenses incurred as a result of your injuries caused by medical negligence. Loss of earnings should include dates off work and monthly net salary.

Further Information:

How did you originally hear about us?
specifics:

We will also send you a form of authority requiring your signature to permit access to your medical records which must be returned. You can submit all of this information to us via email at our medical negligence dept., by using the details on our contact page or by contacting one of our personal injury specialists listed below. Please be sure to label all correspondence clearly with your full name and address.

For further information, please do not hesitate to contact our Personal Injury specialists:


		Kevin Campbell Get in touch with Kevin by clicking here				Dorian Williams Get in touch with Dorian by clicking here


	How We Can Help

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		Personal Injury

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