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Confidential Medical Experience Review
This form is intended for individuals who believe they may have experienced harm in a medical setting and prefer to share their experience in writing.
There is no obligation, and not every submission will result in further action. All information is reviewed with care and discretion.
Full name
*
Email address
*
Phone number
State
Date of incident (Approximate if unsure)
Where did this occur?
Where did this occur?
A
Hospital
B
Clinic/Doctor's office
C
Emergency room
D
Outpatient facility
E
Other/Not sure
Please describe what happened
Are you currently receiving medical care related to this?
Are you currently receiving medical care related to this?
A
Yes
B
No
C
Not sure
Did you consult a lawyer about this matter?
Did you consult a lawyer about this matter?
A
Yes
B
No
C
Not yet
Optional: Upload relevant documents
Click to choose a file or drag here
Size limit: 10 MB
Acknowledgment
*
Acknowledgment
I understand that this submission is for initial review only and does not create a medical or legal professional relationship at this stage
Thank you for sharing this.
Your submission has been received and will be reviewed.
If additional information is needed, we will follow up.
Submit