Medical Malpractice Intake | Richardson Richardson Boudreaux

URL

This field is for validation purposes and should be left unchanged.

Name of injured party*

Phone Number*

Email Address*

Relationship to injured party*

Date of birth of injured party*

Date of incident*

Date the injury was discovered*

If deceased, date of death

Injuries / damages related to the above issues*

Check all boxes that apply

Death

Catastrophic injury that resulted in need for life-long care or special accommodations

Permanent disability/loss of functioning

Severe disfigurement, deformity, loss of limb or scarring

Lost wages

Inability to perform any gainful employment

Pain and suffering

Loss of consortium (loss of companionship, comfort, sexual relations or the ability to bear children)

Other

Other, please specify.*

Patient height*

Patient weight*

If you are a smoker, please indicate the # of packs per day and # of years that you have been a smoker

Please describe any chronic health conditions*

For which you take medications and/or receive ongoing treatment

Please describe your CURRENT health condition*

Related to the injury mentioned above

Medical Malpractice Questionnaire