Colorado Law.com

Client Information Sheet
Medical Malpractice

Personal Information
Full Name: Birthday:
ADDRESS: SOCIAL SECURITY NO.
City: State: Zip Code:
Phone, Work: Home Phone:
Spouse: Name: Work Phone:
Name of person other than your spouse who should always know your whereabouts:
Name: Relationship:
Work Phone: Home Phone:
Description of the substandard care:
Date you discovered the substandard care:
How did you discover the substandard care:
Medical provider at fault:
Name:
Address:
Telephone:
Current treating physician:
Name:
Address:
Telephone:
Injuries suffered because of the substandard care:
List all doctors that have treated you in the past ten years:
Name:
Address:
Telephone:
Description of treatment:
Name:
Address:
Telephone:
Description of treatment:
Name:
Address:
Telephone:
Description of treatment:
Loss of Wages
Were you employed at the time of this incident?
Name of employer:
Address:
Occupation:
How long have you worked there?
Hours worked per week: Regular hourly wage:
Overtime per week: Overtime Rate:
Are you working now?
If time lost from work:
Regular hours lost from work:
Overtime hours lost from work:
Total loss of wages to date:
If you are not employed, please identify:
Last employer:
Address:
Last date you worked there:
Insurance Information
Health insurance company:
Policy holder:
Policy / Claim number:
Adjuster name:
Address:
Have you submitted a claim to the medical provider's insurance company?
Has anyone from the medical provider's insurance company contacted you?
When? To Whom did you speak?
Did you give a written or recorded statement?
Do you have a copy?
How did you hear about Colorado Law.com:
If TV, what time of day did you see the advertisement:
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