John H. Rowley, medical malpractice attorney

BRIEF QUESTIONNAIRE ABOUT YOUR POTENTIAL CASE

Please fill out this form as completely and accurately as possible. Once you have submitted the completed questionnaire to me, I am usually able to provide a response by email or by phone within
one to two days.

I DO NOT CHARGE FOR THIS SERVICE. SUBMISSION OF THIS COMPLETED QUESTIONNAIRE DOES NOT OBLIGATE YOU TO ANYTHING, NOR DOES IT ESTABLISH AN ATTORNEY/CLIENT RELATIONSHIP.

Name:
E-mail address or N/A:
Phone number:

I live in - City:

State:

Are you the person to whom the incident(s) occurred?

Yes

If not, the patient’s name:
and relationship to you:

Briefly describe (in a paragraph or two) what happened that causes
you to investigate whether a medical malpractice claim should be brought?

Although you may not have medical expertise, please describe, if
you can, what you believe the healthcare provider(s) did, or did not
do, that was unreasonable and caused the injuries or death?

When did the conduct in question occur?

Month: Day: Year:

Where did the conduct in question occur?

City: State:

Patient’s age at time of treatment:

Please generally describe the nature of the
damages or injuries sustained by the patient.

Do you already have an attorney who is presently representing
the patient or his/her family concerning this matter?

Yes: No:

Do you request that I contact you to discuss this
matter further at no obligation to you.

Yes: No: