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Free Birth Injury Lawyers Consultation
Case Information:
Child's Name:
Child's Date of Birth:
(ex. mm/dd/yyyy)
Date of Incident:
*
City where incident occured:
*
State where incident occured:
*
What has the child
been diagnosed with?
What is your relationship to the injured child?
Describe injuries suffered:
Doctor's name and address:
(if known)
Hospital that delivered child:
Hospital Location
(City and State):
Why do you feel that it the doctor's or hospital's
negligence caused the injury to the child?
Was this a vaginal delivery?*
Yes No
Is the child deceased?*
Yes No
If deceased, date of death:
Was there an autopsy performed?
Yes No
If deceased, what is the cause of death
as stated on the death certificate:
Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:
Please explain the full extent of the victims injuries:
Comments / Additional Information
Is there anything else that would assist us in
understanding the facts of your case?
To Better Serve You:
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If you found us using a search engine,
please tell us which search engine?
Please tell us exactly what terms you typed into the
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