DO I HAVE A CASE?

Free Claim Evaluation
Medical Malpractice/Catastrophic Injury

If you suspect that you have a case and that it may have been caused by medical mistake, malpractice or negligence, please contact our office for a free evaluation by filling out the form below. This should be done as soon as possible to maintain your rights under applicable statutes of limitations.

Contact Information:

Please complete all of the items that apply. We will review your information and respond promptly to your request.

Name: 

Address: 

Phone:  123-456-7890

Email:   email@provider.xxx

When is it best for us to contact you? 

How would you prefer to be contacted? 

Information About the Person with Injury/Condition

Name: 

Date of Birth/Age: 

What is your relationship to the injured? 

Has a medical diagnosis of been made?  Yes  No

If yes, please explain:

If a medical diagnosis has been made, how old was the individual at the time of diagnosis? 

Additional Information

Have you previously sought legal assistance regarding a possible medical malpractice claim?  Yes  No

What State are you in? 

What State did the Injury occur in? 

In the box below, please describe your case and tell us what you think was done wrong.

 

If you would like to contact us directly we can be reached at:

800-947-2176 Toll Free

(952) 952-4005

medmal@hjlawfirm.com

 

Please note: this request for a case evaluation does not constitute an attorney-client relationship.



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