Your full name:

E-mail Address:
  (Required)

Mailing Address:

Home Number:

Work Number:

Best time to reach you if you prefer a response by telephone:

How would you like for us to respond to you (e.g., telephone, e-mail, regular mail, doesn't matter)?

On what date were you injured?

Where were you hurt (City, State)?

Describe the accident which caused your injury as fully as possible:

Who do you believe was a fault in causing your injury, and what do you believe they did wrong?

Do you have any other information which you believe would help us help you?

What are the names of all doctors or hospitals which you believe were guilty of medical malpractice (please give the city where they are located).

What do you believe that each doctor or hospital did wrong that you believes makes them guilty of medical malpractice and when was the malpractice committed (please be as specific as possible).

If any doctor has told you or written that they believe that a doctor or a hospital was guilty of medical malpractice, please tell us the name and address of the doctor and what he or she said or wrote.

What other information do you have that leads you to believe that medical malpractice is involved?

Describe your injuries. If you know, state whether you have a permanent injury. If you know, what are your total medical bills to date?

Have you lost any earnings? Are you still off work? What kind of work do you do, and how much do you earn per week or per month?

Have you suffered any other losses because of this injury and, if so, please describe your losses:

Were you married when the injury occurred and, if so, has your spouse suffered any loss or damage because of your injury?

• Have the medical or funeral bills or lost wages been paid for by:
  Workers Compensation?
  Medicare, medicaid, or some other government program?
  Employer's health plan?
  Private insurance?
  

   

• Are there any other questions you wish answered?
  

   

• Is there any other information that you want to provide us?
  

   

• Would you like to arrange a personal interview?
  

   

• Are there any other instructions you wish to give us?
  

   

Final Instructions

INTERNET SECURITY: Sending information over the internet is not always a secure way to send information. While we will keep the information you send us over the internet CONFIDENTIAL once it is received in our office, we cannot be assured that it will be secure while being transmitted to our office. If you have any concerns about that, please print the information above and mail it to us at:

Wagner, Vaughan & McLaughlin, P.A.
601 Bayshore Boulevard
Suite 910
Tampa, Florida, 33606

THE SERVICE WE PROVIDE: When we receive the information you have provided, we will evaluate the information and then contact you by telephone or by mail at the address and phone number you have given us to tell you:

a. Our preliminary evaluation of the merits of your case
b. Whether we would be willing to represent you.

Obviously, the information you have sent us may not be sufficient to provide full answers to the above matters. If more information is needed, we will contact you to obtain the necessary additional information before we give you our evaluation of your potential medical malpractice claim.

We will try to be in touch with you by mail, telephone, or e-mail within a short time. We are an active law firm with many trials, however, and on occasion the requirements of providing service to our clients may cause us to delay answering you inquiry. If you do not hear from us in a reasonable time, don't hesitate to call. Under most circumstances, you should expect to hear from us within two days of our receipt of your inquiry.

OUR FEES: We charge no fee to provide the limited service described above. If you decide to employ our firm to represent you, we will provide contracts for you to read and sign. We also suggest you read the "Statement of Clients Rights" available from the FAQ Page. If we represent you we are willing to do so on a "Contingent Fee" basis, that is, you will owe us no fee for our services unless we make a recovery for you, and in the event of a recovery, your fee will be a percentage of the amount recovered, as outlined in the written contract we will provide to you.

LIMITATIONS ON OUR SERVICE:

1. The advice we provide is obviously limited by the information you provide to us. Final advice would be based upon a complete evaluation of your entire case. This cannot be accomplished with the limited information you have given us above. Often a full evaluation of a claim cannot be given without collecting considerable information, records, and other investigation. Often a decision about a claim can only be made after a personal interview.

2. Your claim may be barred by the Statutes of Limitations. These statutes provide that if a suit is not brought within a certain amount of time, the claim can never be thereafter brought. Likewise, the information you furnish may be furnished at a time so close to expiration of the statute of limitations that we do not have time to provide any help to you before the time expires. By asking for our help, you agree that we are not liable for failing to file suit on your behalf or failing to take any other action on your behalf.

3. You are not obligated to employ this firm by sending this information. Likewise, we are not obligated to accept you as a client by providing this help to you. We reserve the right to decline to represent you for any reason whatsoever. Once we have provided the limited service mentioned above, we reserve the right to refuse to become involved in further evaluation of your claim or in providing further advice. If we decline to represent you, or to provide additional advice, we will so advice you in writing at the address you have given us.

ADDITIONAL SERVICES: We are available to provide additional advice and services upon written or telephoned request unless we advice you of our decision not to do so as outlined above. Our firm does, however, generally limit its representation to claimants in personal injury, medical and professional negligence, products liability, and wrongful death matters as well as to certain other types or litigation on behalf of individuals (generally not corporations or insurance companies). Please feel free to write us at our Bayshore Office if more information is needed. It always helps to send along as much information as you have to help us help you.