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Erb's Palsy Claim Inquiry Form

There is no charge for this evaluation.

Name:
Email: 
Address:

 Phone:

State:

  Zip:
Contact By:

When?  		 


 
ABOUT THE PERSON WITH ERB'S PALSY
Name:

Date of Birth / Age:

What is your relationship to the injured?   

Other:
Has a medical diagnosis of EP been made?   Yes  No
If a medical diagnosis of ERB'S PALSY has been made,
how old was the individual at the time of diagnosis?
 
MEDICAL INFORMATION
Was the delivery of the child particularly difficult?
Yes  No
Was the birth premature? Yes  No
Did the doctor declare 'fetal distress' during the delivery?
 Yes  No
Do you believe medical errors occurred during labor?
What type of Erb's Palsy of injuries did your child suffer? 
Is full-time care required by either a parent or nurse?  
Yes  No
Additional Medical Information:
ADDITIONAL INFORMATION

Have you previously sought legal assistance regarding a possible medical malpractice claim? Yes  No

Additional Information / Questions / Comments:
How did you hear about us:

Submitting this form does not create an attorney-client relationship.