Medical Malpractice Intake Form

Completing this form is the first step in a medical malpractice claim with Wagners. It is required for our team to start the intake process. Additional questions and details will be requested based on your individual situation after we have reviewed this intake form. Please allow a week for your form to be reviewed by our team and for their recommendations to be provided.

Please correct the errors described below.

Your Information

Injured Person's Information

Please indicate if the deceased had any of the following family members and how many of each:

Your information will be encrypted.

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