Medical Negligence New Enquiry Questionnaire

Full legal name

First

Last

Date of birth

there please a

Childs full legal name

First

Last

Childs date of birth

Phone

Email

Current address

Address Line 1

City

State / Province / Region

Postal Code

Previous addresses if medical records may be different

Address Line 1

City

State / Province / Region

Postal Code

PPS number

What date did the incident/treatment/surgery occur?

What condition or problem was being treated?

What treatment or care was expected

What actually happened? (Please describe clearly in your own words):

What harm, injury, or problems were experienced as a result?

Where do you think there was negligence

Did any healthcare professional explain the risks or possible complications before treatment?

Was a consent form signed before the treatment?

Who was responsible for the negligence

Have you lodged a formal complaint withe doctor/hospital - if yes, please send in copy of correspondence and decision

How are you now?

Has there been an inability to work or any loss of income because of this incident?

Name of all doctors, hospitals, physios etc that would have medical records

Do you have any medical records, letters, or documents about the treatment?

Has legal advice been taken or a claim been made previously - if yes, give a short info

Any other important info