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MedMal Web Intake Form

Name *

Date of Birth

Cell Phone *

Home Phone

Work Phone

Email Address *

Street Address

City *

Province

Postal Code

If you are contacting us on behalf of someone else, please provide that person’s full name, date of birth and your relationship to that person

Date of the incident/event that caused harm *

Name of the doctor(s) / nurse(s) / hospitals(s) who was at fault *

Brief description of what happened *

Brief description of ongoing symptoms and problems *

Brief description of how the symptoms have affected your life (eg. not able to work, need help around the house etc.)

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