Medical Malpractice Case Evaluation

NOTE: An asterisk (*) indicates REQUIRED information. The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

  

Contact Information
*First Name:   
*Last Name:   
*Email Address:   
*Phone:   
Alt. Phone:   
Address:   
City:   
State/Province:   
Zip:   
 

Injury Person Information
Whom are you inquiring on behalf of?    SelfMinorOther
If you are NOT inquiring on your own behalf, what is your relationship?   
Is the person deceased?    YesNo
If deceased, the cause of death, as stated on the death certificate.   
 

Injury Information
What is the date of the alleged malpractice?   
What is the name of the physician(s) or medical provider who you think committed the malpractice?   
Describe what you believe to be the alleged malpractice.   
Describe the condition that you now have as a result of the medical malpractice.   
Is your current condition permanent?    YesNo
What Dr. have you seen regarding your current condition   
What Dr. have you seen regarding your current condition   
Who referred you to Johnson, Clifton, Larson & Schaller?   
 

Closest Living Relative
Name:   
Address:   
Phone:   
  
 

Comment
* Please add any additional information that you would like us to consider.

The Oregon personal injury trial attorneys at Johnson, Clifton, Larson & Schaller, P.C. represent plaintiffs in personal injury and wrongful death cases involving medical malpractice, motor vehicle accidents, truck accidents, disabled persons' tort claims, nursing home negligence or elder abuse, construction and industrial accidents, birth injury cases, and product liability and defective medical device cases. Our Eugene medical malpractice lawyers serve clients throughout central Oregon, southern Oregon, and the Willamette Valley, including Corvallis, Salem, Medford, Roseburg, Klamath Falls, Bend, Redmond, Ashland, Creswell, Central Point, Grants Pass, Brownsville, Myrtle Creek, Springfield, and Albany, OR.

Lane County ◦ Marion County ◦ Benton County ◦ Douglas County
Print This Page

FirmSite® by FindLaw, a Thomson Reuters business.