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Emails
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Type
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Work
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Primary
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Are you the injured party?
Yes
No
What is the name of the injured party?
What is their relationship to you?
Date of Birth of Injured Party
Gender of the injured party?
Select an option
Male
Female
Marital Status of the Injured Party
Select an option
Single
Married
Divorced
Widowed
Is the Injured Party currently employed or was employed at time of incident?
Yes
Employer Name
Title
Wage
No
Background
Briefly describe the medical condition you or a loved one was seeking treatment for:
Date of the incident you believe constitutes malpractice:
Doctor(s) or facility (ies) involved: (Name, Hospital, Clinic, etc.)
Where did the alleged malpractice take place? (be specific)
What went wrong? Please describe the incident in your own words
Potential Malpractice
What type of medical malpractice you think occurred? (Please select all that applies)
Medication Errors
Surgical Errors
Birth Injuries
Anesthesia Errors
Failure to Obtain Informed Consent
Hospital and Nursing Home Negligence
Failure to Warn of Risks
Other
Not Sure
Misdiagnosis or Delayed Diagnosis
Did you or a loved one suffer any injuries or complications as a result? (Briefly describe)
Additional Information
Do you have any medical records related to this incident?
Yes
Please describe what you have
No
Are you able to get medical records for Attorney review?
If readily available please upload any documents you may have. If not please email to: admin@gmageorgia.com as soon as possible.
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Have you consulted with another doctor about this issue?
Yes
What was their opinion or assessment?
No
Disclaimer
This questionnaire is for informational purposes only and does not constitute legal advice. Please be aware that this does not establish an attorney-client relationship.
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