Below is the medical malpractice intake form we use when a new client calls with potential medical malpractice claims. If you are wondering what questions we will be asking if you call us, these are the questions we will be asking you about your potential claim. You can know exactly what to expect.
This is very detailed. You do not need to know the answer to every question. But we do need to get a general understanding of what happened in the case and what the gist of any potential negligence claim could be.
Sample Medical Malpractice Intake Form
CALLER INFORMATION
Caller Name:____________________________________ Relationship:_____________________
Home:_____________________ Work:_____________________ Cell:_____________________
Email:_____________________
Preferred Method of Contact:____________________________________
INJURED PARTY’S INFORMATION
Injured Party’s Name:____________________________________
DOB:_____________________ Married:_____________________ Spouse
Name:____________________________________
○ Minor ○ Disabled ○ Deceased Date of Death:_____________________
Address:________________________________________________________________________
City:____________________________________ State:____________________________________
Zip:__________________
Home:_____________________ Work:_____________________ Cell:_____________________
Email:____________________________________
Preferred Method of Contact:____________________________________
Name/number of someone who will be able to reach you:_____________________
MEDICAL NEGLIGENT INFORMATION
What injuries were sustained:
Date of suspected negligence:
What do you claim a doctor/provider did or did not do to cause an injury?
Who is the claim against:
What date were symptoms first noticed:
Did the injury require additional surgery:
Where:_____________________ Surgeon:_____________________ Date:_____________________
Any follow up treatment (dates and locations and treatment provided):
Current health status/treatment/permanency of injuries sustained:
Caller/Injured in possession of medical records?:
Subsequent treating doctor’s comments:
Did a treating doctor recommend any treatment that the injured declined? If so, what was recommended and why was it declined?
CALLER/INJURED INFORMATION
Injured’s health prior to injury, to include any and all illnesses and conditions the injured had prior to claimed negligence:
Injury occurred during routine, elective, emergency medical treatment?:
Did the injured miss time from work?
How long?:_____________________ Job:_____________________
SSDI:_____________________ Reason (mental or physical):_____________________
Disability Award related to this incident?:
IF DECEASED
Date of Death:_____________________ Place of Death:_____________________
Copy of Death Certificate:_____________________ Cause listed on Death Certificate:_____________________
Autopsy performed:_____________________ Where:_____________________
Copy of Autopsy Report:_____________________
Does Death Certificate state that the Autopsy report was available before cause of death was determined:
Was an estate opened:_____________________ PR:_____________________
Does Caller have a Letter of Administration:
Names and ages of all surviving children:
Prior Medical History:
- Diabetes
- Hypertension
- Vascular Disease/vein grafting/
- Heart disease/stents/open heart surgery/
- Stroke
- Hernia
- Ob/Gyn Operations
- Amputations
- Seizures
- Head Injuries
- Broken Bones
- Liver Disease
- Kidney Disease
- Eye Injury/operations/
- Bladder problems / Bladder Sling
- Gastric Bypass Surgery
- Colonoscopy
- Cancer
- Hepatitis / Any autoimmune disease/
- Gall Bladder disease/surgery
- Appendicitis
- Sepsis
- Dementia
- Pancreatitis
- Fibromyalgia
- Any mental health care/psychologist/psychiatrist
C.O.P.D.
Transplant surgery
Other operations:
Health Insurance:
Medicare:
Medicaid:
Federal Employee Insurance:
Tri Care:
ADDITIONAL NOTES OR COMMENTS
GUARDIAN/REPRESENTATIVE INFORMATION
(If applicable (i.e.: death, minor, disabled))
Guardian:_____________________ Relationship:_____________________
Address:
City:_____________________ State:_____________________ Zip: _____________________
Home:_____________________ Work:_____________________ Cell:_____________________
Email:____________________________________
Preferred Method of Contact:_____________________
INTAKE INFORMATION
Intake completed by:____________________________________ Date:_____________________
Reviewed by attorney:_____________________ Date:_____________________
○ Decline ○ Accept ○ Refer Out ○ Will Review Records ○ Opened in TM
FOR FIRM USE
How were you referred to our firm:________________________________________________________________________
Have you consulted with another attorney:_____________________
Attorney Name & Date of Consult:________________________________________________________________________
- PDF Version of another malpractice intake form
Random Thoughts on Malpractice Intakes Sample Documents
When handling malpractice intake calls, it is essential to recognize that potential clients often have experienced significant trauma or loss. The person conducting the intake must possess genuine compassion and empathy for human suffering. Without this quality, they may not provide the necessary support and understanding to the caller, which is crucial in such sensitive situations.
The skills required for a successful intake are akin to those needed when deposing a witness, albeit with a very different vibe. It is not sufficient to merely read through a list of questions and record answers. Active listening and thoughtful follow-up questions are vital. This approach ensures that all relevant details are gathered during the initial conversation, saving time and potentially significant costs for the lawyer and client.
Experience is another critical factor. The person conducting the intake should have a deep understanding of what constitutes a viable malpractice claim. This often means having a background in both law and healthcare. For instance, a nurse-lawyer with extensive experience can effectively identify the nuances of malpractice cases. Such professionals bring invaluable insights, having seen a wide array of cases and understanding both medical and legal standards.
Incorporating these elements into your malpractice intake process can enhance the quality and effectiveness of your initial client interactions. Here are some additional tips:
- Empathy and Active Listening: Ensure the intake staff is trained in empathy and active listening. Job #1? Be a human being, not a robotg. Build sincere rapport with potential clients and encourage them to share all necessary information.
- Detailed Documentation: Develop comprehensive intake forms that prompt for detailed information about the incident, medical history, and the impact on the client’s life. Ensure these forms are user-friendly and easily understandable.
- Follow-Up Questions: Train intake personnel to ask follow-up questions based on the client’s initial responses. Some many peopl skip this part. This ensures no crucial detail is overlooked.
- Screening Criteria: Establish clear criteria for what constitutes a viable malpractice claim. This can include specific medical errors, deviation from standard care practices, and demonstrable harm caused by these errors.
- Professional Expertise: Utilize professionals with relevant expertise for intakes. Our frim has a nurse-lawyer who does most of our malpractice intakes in serious cases. You do not need that but you need someone sophiscated who can provide a more thorough and informed assessment of potential claims.
- Supportive Environment: Create a supportive environment for the intake process. Ensure that clients feel heard and understood, which can help them open up more about their experiences.
Related Links
- Sample malpractice contingency fee agreement
- More sample malpractice forms
- Learn more about medical negligence claims in Maryland
- Summary of Maryland law as it relates to malpractice
- Decrease chance of malpractice by getting the right doctor
- Value of malpractice cases
Contact Us
Our lawyers fight for medical malpractice victims. If you are a victim or you are a lawyer who has a case they may wish to refer to us with a fee split consistent with Maryland Rule 1.5, call 800-553-8082 or reach out to us online.