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Shreveport Office
705 Milam St.
Shreveport, LA 71101

Toll-Free: 800-619-6444
Phone: 318-227-2401
Fax: 318-221-4762

Potential Client Information Sheet

Thank you for visiting our website. If you would like our firm to consider representing you in a medical malpractice claim, please fill in the blanks on the form below and press submit. An attorney will review the information and respond to you by email within three business days.

Fields marked with * are mandatory

* Your Name:

* Email Address:

Address:

Home Phone:

Work Phone:

Patient Information:

Name:

Spouse:

Address:

Date of Marriage:

Patient's Children:

Defendant Information

Name:

Address:

Date of Discovery:

Date of Malpractice:

Other physicians who have
treated patients related
to this problem:

Hospital Admissions Information

Name:

Address:

Dates of Treatment:

Summary of your complaint:

Medical Problems arising out
of this occurrence:

Did patient die as
a result of
the malpractice?:

Yes

If yes, date of death:

Comments/Questions:

This questionnaire is for informational purposes only and does not constitute a contract.

* Identification Code

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