Name: Sweeney Merrigan Personal Injury Lawyers
Rating: 4.9 (113 reviews)

Save and Continue Later

Please describe any conscious pain that you suffered as a result of the injuries caused by the defendant:
Generally, in your own words, how did this incident occur?
Who was your primary care physician at the time of the events?
Please describe your educational and professional history:
Please state any conversations and/or communications you are aware of with the defendants:
Are there any writings or notes or journal entries about the incident? If so, please explain:
Were you Medicare eligible at the time of the incident? Please answer "Yes" or "No":*
What health insurance did you have at the time of the incident?
Did you suffer monetary losses, lost wages, or lost benefits as a result of this incident? Please explain:

Save and Continue Later

Please upload any Medical Records relating to the incident above.
Drop files here or

Max. file size: 512 MB.
Please upload any Medical Records relating to the incident above.
Please upload your Autopsy Report above.
Drop files here or

Max. file size: 512 MB.
Please upload your Autopsy Report above.
Please upload any Medical Bills or Hospital Bills resulting from the incident above.
Drop files here or

Max. file size: 512 MB.
Please upload any Medical Bills or Hospital Bills resulting from the incident above.
Please upload any Photographs or Videos relating to the incident above.
Drop files here or

Max. file size: 512 MB.
Please upload any Photographs or Videos relating to the incident above.
Please upload any and all Investigative and/or Incident and/or Accident Reports above.
Drop files here or

Max. file size: 512 MB.
Please upload any and all Investigative and/or Incident and/or Accident Reports above.
Please upload copies of all Lien Letters and Notices relating to this litigation from CMS regarding Medicare/Medicaid liens above.
Drop files here or

Max. file size: 512 MB.
Please upload copies of all Lien Letters and Notices relating to this litigation from CMS regarding Medicare/Medicaid liens above.
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Medical Malpractice Onboarding Form – Client

Meet the Personal Injury Attorneys at Sweeney Merrigan Law, LLP