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Medical Malpractice Form

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We change lives for the better.
We do what we say we will do.
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We don’t treat people like a case number.
We do the right thing.

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First Name*

Last Name*

Injured Party*

If OTHER

First/last Name

Date of Birth*

(Injured Party)

Date of Injury*

Death Involved?*

Does this case involve a death?

Married?*

If yes, was the deceased married at the time of the incident?

Children?*

If yes, did the deceased have children under the age of 25 at the time of the incident?

Preferred Method of Contact

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Your Email Address*

Email Address Confirm Email Address

Best Time to Call You*

What is the name of the doctor and/or medical facility involved?*

What did the doctor or medical facility do wrong?*

Have you gotten a second opinion from any other doctor or medical facility?*

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Sarasota - Main Office

Our Locations

Address:

2803 Fruitville Rd.

Sarasota, FL 34237

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Lakewood Ranch

Lakewood Ranch

Address:

8130 Lakewood Main St.

Suite 103, #366

Lakewood Ranch, FL 34202

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Port Charlotte

Port Charlotte

Address:

18245 Paulson Dr.

Port Charlotte, FL 33954

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Brandon

Brandon

Address:

1218 Millennium Pkwy.

Brandon, FL 33511

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Bradenton

Bradenton

Address:

4916 26th St. W.

Bradenton, FL 34207

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Venice

Venice

Address:

871 Venetia Bay Blvd.

Venice, FL 34285

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Home Office

Sarasota
Address:2803 Fruitville Rd.

Sarasota FL, 34237

Call:(941) 735-4529

Lakewood Ranch

Lakewood Ranch

Address:8130 Lakewood Main Street

Suite 103, #366

Lakewood Ranch, FL 34202

Call:(941) 735-4529

Port Charlotte

Port Charlotte

Address:18245 Paulson Dr.

Port Charlotte, FL 33954.

Call:

Brandon

Brandon

Address:
1206 Millennium Parkway.

Brandon, FL 33511

Call:
(813) 793-7738

Bradenton

Bradenton

Address:
4916 26th St. W.

Bradenton, FL 34207

Call:
(941) 735-4529

Venice

Venice

Address:871 Venetia Bay Blvd.
Suite 201
Venice, FL 34285

Call:
(941) 735-4529

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