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Contact Information |
* First Name
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| * Last Name |
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* Email
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* Phone
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Alt. Phone
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Address
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City
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State/Province
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Zip
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Injured Person Information |
| Whom are you inquiring on behalf of? |
Self Minor Other |
| If you are NOT inquiring on your own behalf, what is your relationship? |
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| Is the person deceased? |
Yes No |
| If deceased, the cause of death, as stated on the death certificate. |
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Injury Information |
| Date the neglect or abuse occurred |
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| What is the name of the facility where the abuse or neglect occurred? |
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What is the address of the facility? |
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| Describe the abuse or neglect. |
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| Name of witnesses to the abuse or neglect. |
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| Identify medical providers that criticized or commented on the care given. |
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| Do you know of anyone else who was abused or neglected in a similar manner as the patient? |
Yes No |
What is the current medical condition of the patient?
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Who referred you to Ryan, Bisher, Ryan?
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Closest living relative |
| Name |
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| Address |
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| Phone |
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Comment |
* Please add any
additional information that you would like us to consider.
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Any information that you send to Ryan, Bisher, Ryan in the form of an e-mail does not create an attorney-client relationship. Ryan, Bisher, Ryan can only acted as your lawyer in any matter you submit if an attorney from our firm and you expressly agree in writing that we will serve as your attorney.
There are Statute of Limitations on all legal matters that impose a time period within which you may assert claims or file lawsuits. If you think you might have a claim or a potential lawsuit please contact one of our lawyers as soon as possible to protect your legal rights. |
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