Medical Malpractice Intake Form | Kortum Law Office, Kalispell law firm

Please complete this Medical Malpractice Intake form. Our website is secure and the date is encrypted to ensure safe transmission of your personal information.

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Medical Malpractice Intake Form

Name *

Address *

City *

State *

Email Address *

Home Telephone *

Cell Phone

Work Telephone

Social Security Number *

Date of Birth *

Referred by:

Previous counsel? If yes, please list

Doctors / Facilities Involved

Description of Issue: *

Date of Discovery of Injury Due to Malpractice *

Prior Injuries or Health Issues *

If Yes, When?

If Yes, What Were the Injuries?

Are You a Medical Marijuana user? *

Name of Your Health Insurance

Insurance Member ID

Insurance Group Number

Insurance Contact Information

This form is completed by: *

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