Site Menu

Call us at

877 TiMedLaw

877 846 3352

727 346 6489

Fax 888 499 2558

28870 US Hwy 19N #300

Clearwater, FL 33761-4327

adt@TiMedLaw.com

Submit your information

You may get a message stating "To help protect your security, Internet Explorer has restricted this webpage from running scripts or ActiveX controls that could access your computer. Click here for options...

This webpage uses JavaScript to tailor to your particular patterns.
You need to allow JavaScript to run do that - by
1. clicking on the Alert bar
2. selecting Allow blocked content....
3. click Yes to Are you sure you want to let this file run active content?
4. The JavaScript enabled webpage will load automatically
If not, then use this form, which has all the questions needed, and just skip the parts that don't pertain to you

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: E-Mail:

Phone - Home: Cell: Work:

Street Address: City: State: , Zip:

Information - for all cases

Date of the malpractice (in YYYY-MM-DD format):
*Date you suspected there was malpractice:
The resulting harm: If the malpractice had not occurred, how would things be different now and in the future?
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?

Cancer Death Failure or delay in diagnosis Failure or delay in treatment Problems after surgery or a procedure	Object left behind Disfigurement Infection Wrong drug 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 - from the patterns above.
Fill out only the sections that apply to your case.

Cancer

What area of the body did the cancer start?
What was the cell type and stage at diagnosis?
What is the current stage and outlook?

This category requires another category - often a delay in diagnosis.

Death

Is there a surviving spouse who will live long enough to bring a claim?
Is there a child under 25 or otherwise dependent on the deceased person?
Was there an autopsy?
Do you have the autopsy report?

In Florida, typically only a surviving spouse or dependent child can bring a medical malpractice claim.

This category requires another category.

Failure or delay in diagnosis

What were the symptoms?
What was the wrong diagnosis?
What was the right diagnosis?
How did you get the right diagnosis?
When should the diagnosis have been made?
When did it get made?
How long specifically was the delay (for example, 3 months)?

Failure or delay in treatment

What was the diagnosis?
What was the right treatment?
When was the right treatment given?
When should it have been given?
How long specifically was the delay (for example, 3 months)?

Problems after surgery or a procedure

What was the reason the surgeon recommended the procedure?
What was the actual mistake that led to your harm?

Object left behind

What is the object?

What was the procedure when the object was left behind?

When did you find out it was left behind?

Where is the object now?

Disfigurement

What was the reason the surgeon recommended the procedure?

Please email "before and after" pictures of the affected area with your name and contact information to adt@TiMedLaw.com

Infection

What was the condition for which you were being treated?
What was the bacteria or virus that you were infected with?
What was the actual mistake that led to the infection?

It is usually hard to prove that an infection was caused by malpractice.

Wrong Drug

What was the condition for which you were being treated?
What drug was given?
What should have been given?

Recall

What drug or device was recalled?
Where is the device or drug bottle now?
Do you have the Device ID card?
Why was it recalled?
Did you suffer from the recall? How?

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.

Site Menu

Submit your information

Specific questions - from the patterns above. Fill out only the sections that apply to your case.

Specific questions - from the patterns above.
Fill out only the sections that apply to your case.