Home > Medical Malpractice Intake Medical Malpractice Intake Form New Medical Malpractice Intake Form INTAKE: Good Morning/Afternoon, thank you for calling Oatley Vigmond. My name is xxxx, and I’m here to help. May I have your name and email please? Caller Name: Caller Phone Caller Email: INTAKE: Thank you. I want to start off by expressing how sorry I am that this happened to you or your loved one. We are supposed to be able to trust our medical professionals to treat us correctly and with respect. I understand that making this call is very difficult in the circumstances. I am going to take you through some questions about the incident so that our lawyers can help determine the best course of action. I’m going to ask you about yourself (or loved one), first, then ask some questions about that accident and finally about the injuries you sustained. I know that some of these questions might be difficult to answer, so please take as much time as you need. I’m here to help you through the process. Is that ok? How old is the injured person? Please provide their Date of Birth (Month Day Year). Was the injured person employed before the incident ? What did the injured person do for a living? Full time or part time or self employed? INTAKE: I am now going to ask you some questions about the medical treatment you received. I know these questions might be hard, but they are important. At the same time, it is ok if you don’t know the answers to all of the questions. 1. Can you please tell me about the illness and symptoms and when this started. 2. Can you tell me about the treatments received and health care providers involved in treatment, such as the facility/hospital, doctors or any other health care professionals. 3. Can you tell me about the mistake the health care provider made? Can you identify the individual and where and when. 4. What was the impact of the mistake? 5. When did the mistake happen? If possible, could you please tell me any significant dates of surgery or procedures. 6. When did you become aware of the mistake? 7. Is there any other information/concerns about the incident that you wish to share at this time? INTAKE: I am now going to ask you some questions about the injuries you sustained as a result of the care you received. Again, it is ok if you don’t know the answers to all of the questions, just do your best. Questions about the injuries 1. What injuries did you/they sustain as a result of the care you received? 2. Are you/they receiving any treatment for the injuries at the present time? 3. Have the injuries prevented you/they from working? If “No”, have they returned to work full time or in what capacity? 4. Aside from work, do the injuries interfere with your/their day-to-day life? Firm and Lawyer Questions 1. In order to ensure that you are connected to the right lawyer, can you tell me how you found out about our firm? 2. Did they refer you to a specific lawyer? Conclusion INTAKE: Thank you for sharing this information with me. The next step is for our lawyers to review this information in detail and determine the best course of action. When would be a convenient time for a consultation, and what is the best way to contact you? INTAKE: Thank you xxxx. Someone from the Oatley Vigmond team will get back to you to confirm the next steps once the lawyers have had an opportunity to review your case. Again, thank you for calling Oatley Vigmond. Rich Text Visual Text Submit If you are human, leave this field blank.
