Tell Your Story

Story Title *

Doctor's Credentials *

Doctor's First Name *

M.I.

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Doctor's Last Name *

Doctor's City *

Doctor's State *

Doctor's Phone Number *

Doctor's Photo

Your Name *

Victim's Name (can be an alias)

Relationship to you

Were other doctors involved in making the error?

What are their full names?

Hospital/Facility where Doctor(s) practice

Approximate date of incident *

Type of mistake *

Explain the type of mistake *

Result of mistake (irreparable injury? Death?) *

Do you have documentation to support the mistake? *

Did the Doctor or hospital admit the mistake? *

What did they do to make it right?

How did the incident affect you and your loved ones?

Any additional comments, facts you want to share?

Would you like to be contacted by an attorney if one is interested in your story?

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