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INJURED PARTY INFORMATION

Callers Name:

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Other Phone:

E-Mail Address:

FACTS AND DAMAGES

Date of Incident:

Date Discovered Problem:

City Incident Occurred:

Describe how the problem came about:

Did this result in death:

If no, what are the resulting injuries/disabilities:

Do you anticipate furture medical problems:

Will you require futher surgery(ies):

Briefly describe the medical condition/problems prior to this incident:

Have you made a formal complaint to doctor/hospital:

Has this ever gone before Medical Review Panel:

Doctor(s) Involved:

Pharmacist/Pharmacy Involved:

Hospital Involved:

Do you have your medical records with reference to this incident:

Have you contacted another law firm in reference to this incident:

How did you hear about our firm:

Additional Comments:

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The Cochran Law Firm - NO, 1580 LL&E Tower, 909 Poydras Street, New Orleans, LA 70112

Louisiana Medical Malpractice Lawyer & Attorney : The Cochran Law Firm New Orleans : Serving Baton Rouge, Shreveport, LaFayette, Lake Charles, Kenner, Bossier City, Monroe, Alexandria, New Iberia : Medical Negligence, Birth Injury, Cerebral Palsy, Failure to Diagnose Heart Attack, Stroke, Cancer.

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