Potential Case Submission – Medical Malpractice Few of the fields below are mandatory. Fields noted with an asterisk are mandatory. To ensure a more complete evaluation of your claim, please fill in with as much information as you can. Your Name Name of Patient (if different) Patient Age Your Relationship to Patient Street Address State Zip/Postal Code Daytime Phone Cell Phone Fax Alternate Phone Email Name and area of practice of first treating physician involved Name and area of practice of second treating physician involved Name and area of practice of third treating physician involved Name and location of hospital/clinic involved Date of Incident Giving Rise to Claim Description of Claim If applicable and known, in brief terms what diagnosis and prognosis have the current physicians given the patient? If this is a case of a missed diagnosis, what diagnosis was initially given? Amount of medical expenses incurred as a result of the medical negligence What was the name of the health insurer that paid your medical bills Did you lose any wages as a result of the mistreatment If so, who was your employer? How long were you out of work? What were your wages at the time? Do you have copies of your medical records? If so, which records do you have? How were you referred to Riley Law Firm? Have you consulted with any other lawyers regarding this claim? If so, please identify the lawyer(s) and state whether you have an agreement of representation with the lawyer(s). Has this matter previously been in litigation or arbitration? If so, please describe when and where and the current status of the matter. By submitting this inquiry to Riley Law Firm, you are agreeing to all of the following: You do not have a lawyer-client relationship with Riley Law Firm, and are not creating such a relationship by the submission of this form. No lawyer-client relationship will arise between Riley Law Firm, or any of its lawyers, and you until and unless a written representation agreement has been signed by both parties. Your submission of this information to Riley Law Firm was not solicited by Riley Law Firm, but rather was initiated by you after reading about Riley Law Firm on its website. You do not have a retained lawyer in connection with this matter, except as may be specifically disclosed above. I agree to the above. Note, before submitting this form, please enter the code you see displayed below.