Please review the "Do I have a Case" and "Patterns" web pages and submit as much of that information as you have.

Background - the injured person

Title: Gender: Age:

First Name:

Last Name:

How did you here about TiMedLaw?

Which one:

Contact info - the person to contact about this case

Full Name:
Email:
Home Phone:
Cell Phone:
Work Phone:
Address:
City
State		Zip:

Key Facts

Date of the malpractice (in YYYY-MM-DD format):
Date* you suspected there was malpractice:
The negligence: who did what carelessly?
The resulting harm: If the malpractice had not occurred, how would things be different now and in the future?
Proof: How can we show this harm to a jury, if we go to trial?

*In Florida, you usually have only 2 years from when you should have known about the malpractice to file a claim.

Patterns - what does your case involve?

No Yes - Death
No Yes - Cancer
No Yes - Failure or delay in diagnosis
No Yes - Failure or delay in treatment
No Yes - Problems after surgery or procedure
No Yes - Object left behind
No Yes - Disfigurement
No Yes - Infection
No Yes - Wrong drug
No Yes - Recall

If your situation does not fall into these categories, please explain it in the Comments box at the end of this form.

Specific questions based on the patterns you indicated above.

Comments: Please enter any other information that will help explain your situation.

Please type OK here: to indicate that you agree with the following 2 statements. This is required to accept your submission.

Submitting information here does not create an attorney-client relationship
This information is not guaranteed to be privileged.

If you have images or documents to support your claims, you can email them to TiMedLaw by clicking the link below.

Submit your information

Specific questions based on the patterns you indicated above.