MEDICAL MALPRACTICE INTAKE FORM

Completing this form is the first step in a medical malpractice claim with Wagners. It is required for our team to start the process. Additional questions and details will be requested based on your individual situation after we have reviewed this intake form. Please allow 1 to 3 business days for us to review your information before we can respond.

If you are unable to complete this form due to disability or technology limitations, please phone to schedule a phone appointment to have an assistant assist you in completing this form. Please have a copy of the form with you during your appointment to complete the form. Alternatively, we can mail you a paper version for you to complete by hand.

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Date*
MM slash DD slash YYYY
Your name:*
Email:*
Telephone number:
Relationship to the person injured:*
Name of the person injured:*
Date of birth:*
MM slash DD slash YYYY
Date of diagnosis:
MM slash DD slash YYYY
Date the injury occurred:
MM slash DD slash YYYY
Date of death:
MM slash DD slash YYYY
Province or Territory where the injury occurred:*
Type of injury:*
Please describe the injury:*
Length of time this injury resulted in:
Totally disability
Totally disability
# Months
Totally disability
# Years
Partially disability
Partially disability
# Months
Partially disability
# Years
Confined to hospitals
Confined to hospitals
# Months
Confined to hospitals
# Years
Confined to bed
Confined to bed
# Months
Confined to bed
# Years
Confined to home
Confined to home
# Months
Confined to home
# Years
Required caretaker assistance
Required caretaker assistance
# Months
Required caretaker assistance
# Years
Unable to work
Unable to work
# Months
Unable to work
# Years
Do you receive any Long-Term Disability, Canada Pension Plan Disability, or other disability payments you currently receive as a result of this injury?*
What did a health professional do, or did not do, to cause this injury:*
Treatment or surgery required due to this injury:*
Current health status and what treatments are on-going:*
Pre-existing injuries, illness, and/or conditions:*
Daily activities no longer able to perform due to the injury:*
Approximate total expenses incurred due to the injury:*
Approximate loss of income due to the injury:
If this is regarding a fatal injury, please indicate whether the deceased had any of the following and, if so, how many:
Spouse
Parent
Sibling
Adult Child
Minor Child
Grandchild
Grandparent

MEDICAL MALPRACTICE INTAKE FORM

MEDICAL MALPRACTICE INTAKE FORM

Length of time this injury resulted in:

If this is regarding a fatal injury, please indicate whether the deceased had any of the following and, if so, how many: