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Title: First Name*: MI Last Name*:
 
     
E-mail Address*:
  
Home Phone*:  
Work Phone:  
Mobile Phone:
  
Street Address:  
City:   
State / Zip: /  
 

Injured Person Information:

Date of Birth:
Whom are you inquiring on behalf of?  
If you are NOT inquiring on your own behalf, what is your relationship?

Is the person deceased?

Yes No

If deceased, the cause of death
as stated on the death certificate: 

Date of Death:  
Was there an autopsy performed? Yes No   n/a
Where?
   
Is this claim being handled by another attorney? Yes No  
   
Please provide a brief statement as to the nature of the claim*.
(e.g. medical malpractice, auto, fall, construction, etc.)
   
Please provide a brief statement as to when you believe the negligence occured*:
(e.g. June, 3, 2003 or from May 2001 thru June 2003)
   
Please provide a brief description of the injury*:
(e.g. dealth, brain damage, cancer, stroke, cardiac)
   

 

 

 
 
 
Duffy, Duffy and Burdo, Esqs.
Medical Malpractice, Personal Injury Litigation - Uniondale, New York
(516) 394-4200 - mduffy@ddandb.com