Questionnaire

Dental Malpractice Lawyers

Questionnaire

Please fill out the following form to allow us to evaluate your case.

    About You: (all these fields must be entered)





    When did you find out about the alleged negligence by your dentist?


    About Your Case




    Is your dentist part of a dental group?YesNo

    Is your dentist a specialist?YesNo

    Are you still treating with the suspected negligent dentist?YesNo
    Do you have a copy of your dental records, including x-rays?YesNo
    Have you lost earnings or income as a result of your injury?YesNo

    Do you have a spouse who lives with you?YesNo



    Did another dentist/health care provider advise you that negligence may have been present in your care and treatment?YesNo





    Comments

    Who referred you to us?

    Yes Another attorney (who)?
    Yes Another dentist (who)?
    Yes A search engine (which)?
    Other Notes and Comments?

    "I understand that the attorneys of www.dentalmal.com (LEVY LAW FIRM) have not accepted any professional responsibility, are not my attorneys, and they do not represent me in this matter until such time as a written retainer agreement has been entered into and executed by client and counsel."
    YesYou must agree to the above statement by checking this box.
    By submitting below, I certify the information herein to be true and complete to the best of my knowledge and belief.

    Levy Law Firm

    © 2019 www.DentalMal.com. All Rights Reserved.