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Moncton City Hospital Emergency C-Sections Class Action Intake Form

1869 Upper Water Street
Suite PH 301, Pontac House
HALIFAX, NS B3J 1S9
www.wagners.co
Email: [email protected]

Moncton City Hospital Emergency C-Sections Class Action Intake Form

  • MM slash DD slash YYYY
  • Claimant’s Name (Individual who underwent emergency c-section):

  • MM slash DD slash YYYY
  • Claimant Address:

  • Contact Address (If Claimant deceased):

  • Remainder of this form pertains to information about the Claimant

  • MM slash DD slash YYYY
  • Marital Status:

  • Single:Married:Common Law: 
  • Divorced:Widowed:Separated: 
  • Divorce Date:Widowed Date:Separated Date: 
  • Spouse:

  • Children

    (Only to be completed if Claimant is Deceased and child is under 19 years of age):
  • History:

  • Please note that we will never contact any persons listed below without your express consent.

  • Family Doctor(s):

  • Provide details of your family doctor and any other doctors who would possess medical records related to medical conditions and/or treatment received with respect to your pregnancy:

  • NamePhone #Address 
  • NamePhone #Address 
  • Birthing Doctor(s):

  • NamePhone #Address 
  • NamePhone #Address 
  • Specialist(s):

  • Provide details of any Medical Specialists you have seen regarding your pregnancy:

  • NamePhone #Address 
  • NamePhone #Address 
  • NamePhone #Address 
  • NamePhone #Address 
  • Other Physician(s)/Hospital(s):

  • Provide details of any other medical practitioner or facility that would possess medical records related to medical conditions and/or treatment received with respect to your pregnancy:

  • NamePhone #Address 
  • NamePhone #Address 
  • Pharmacies:

  • Provide details of pharmacies that would possess your prescription records:

  • NamePhone #Address 
  • NamePhone #Address 
  • NamePhone #Address 
  • NamePhone #Address