north carolinasouth carolina
Medical Negligence Submission Form

   We are anxious to help you.  There are two ways you can contact us about your case.  You can either call us at 1.800.556.8404 to talk to one of our client service representatives or you can fill out the on-line form below and submit it to us from this website at any time.  After completing the form you may submit it by simply clicking on the I AGREE button after reading our necessary disclaimer. 



Personal Information

Your last Name   Your First Name   Your Gender  

Physical Address (Include City, State, Zip)  
Email Address    
Cell Phone (xxx-xxx-xxxx)   Home Phone (xxx-xxx-xxxx)   Work Phone (xxx-xxx-xxxx)  

 

Accident Information

Name(s) of Person(s) who you believe were medically negligent:
Last Name: First Name Gender



Date of Medical Negligence:  
Date of last treatment by Defendant for this matter:  
Place of Medical Negligence: Name of Healthcare Provider:
City:
State:
Location:

Do you have medical records from:
the person/hospital you believe injured you?
 
other medical providers who have treated you
Types of Medical Negligence. (Note: To be grounds for a law suit the medical negligence must have resulted in serious injury or death).










Injuries - mark all that apply




 
Medical Treatment for your injuries from Medical Negligence - mark all that apply





 
Medical Costs

 
Lost Wages


 
Lost income of disabled/deceased loved one (caused by the medical negligence) for life


 
Describe Medical Negligence (optional):
Describe your injuries (optional):
Have you viewed our tutorial on Medical Negligence?
 
Are you presently represented by an attorney?
 

 

Disclaimer
WARNING:
If you are a Pre-Paid Legal Services, Inc. Member you may not use this method of seeking legal assistance. You must call the 1.800 number on your membership card. If you submit a request in this manner we will not be able to process you as a Pre-Paid Legal member which could result in significant delays.
     
Disclaimer:    
Before you can submit your case for potential review, you must read and agree to the following: "I understand that by submitting this information to MFWWC, I have not created an attorney/client relationship with MFWWC and that MFWWC has no responsibility to protect my interests in this matter in any way unless and until I enter into a signed, written fee agreement with MFWWC. I understand that MFWWC has no obligation to reply to this email and are not responsible for this matter. By clicking on the I Agree button below, I hereby submit my information on this basis and certify that I have read the GENERAL Disclaimer."  





  When you need legal help, we are here to serve you.