Medical Negligence Claim Form
Your details
Name
First Name
Last Name
Address
House Name / Number
Street
Town/City
County
Postal Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Day
-
Month
Year
Date
Occupation
National Insurance Number
*
Marital Status
Please Select
Married
Single
Co-habiting
Separated
Divorced
Other
Do you have any children?
Please Select
Yes
No
If you have children, what are their ages?
Back
Next
Save
Details of the Incident
This section relates to the Hospital / Healthcare Provider that you assess as having provided negligent treatment.
Name of the Hospital / Healthcare Provider
Address
Are you seeking to make a claim on behalf of a family member or spouse who either does not have mental capacity or has passed away due Medical Negligence?
Please Select
Yes
No
If yes, please confirm who you are acting for and whether they lack mental capacity or have passed away.
(If you are unsure, please do feel free to give us a call on 01761 414646 and we will explain the above further).
Back
Next
Save
Details of the alleged Medical Negligence
Date of the accident
-
Day
-
Month
Year
Details of the Medical Negligence
Do you have any pre-existing and/or on-going medical conditions? Please list them below:
Was the negligence reported to someone?
Please Select
Yes
No
If so, who was it reported to?
Have you engaged in the complaints procedure of the health provider / hospital?
Please Select
Yes
No
If so, what was the outcome of the complaint?
If you have any photographs of injuries sustained, letters relating to the injury or any documentation regarding treatment or complaints to the medical provider, please upload them here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Save
Financial Losses and Loss of Earnings
Did you suffer any loss of wages or salary?
Please Select
Yes
No
If yes, how much?
How long were you off work?
You were absent from work from:
-
Day
-
Month
Year
Date
You returned on:
-
Day
-
Month
Year
Date
Your employer's name:
Your employer's address:
Did you receive Statutory Sick Pay?
Please Select
Yes
No
Did you claim SDD Sickness Benefit or Universal Credit?
Please Select
Yes
No
Did you suffer any other financial losses? If so please provide details here
How did you hear about Thatcher + Hallam?
*
Save
Submit
Should be Empty: