Nursing Home Claim

If you wish to receive a free evaluation of the merits of your Nursing Home claim, please provide us with the information requested below. We will forward your claim to one of the law firms in our network. They will evaluate your potential case and discuss its merits and possible value with you; however, the quality of their evaluation is dependent upon the accuracy and quality of the information you provide to us. Again, there is no cost to you whatsoever for this case evaluation.

Your full name:
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E-mail Address:
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Mailing Address:
Tampa Nursing Home Lawyer Tampa Nursing Home Lawyer
Tampa Nursing Home Lawyer Tampa Nursing Home Lawyer
Tampa Nursing Home Lawyer Tampa Nursing Home Lawyer

Home Number:

Work Number:

Best time to reach you if you prefer a response by telephone:

Who was injured?

Is the injured party deceased?

If so, date of death?

Date of Injury?

Name of Facility?

Location Of Injury?

Describe the incident(s) which caused the injury as fully as possible:

Who do you believe was a fault in causing the injury, and what do you believe they did wrong?

Do you have any other information which you believe would help us help you?

Describe the injuries. If you know, state whether the injuries are permanent. If you know, what are the total medical bills to date?

Are there any photographs of the injuries ?

Has the injured party suffered any other losses because of this injury and, if so, please describe the losses:

Is there a living spouse?

If so, spouse's name:

Is there a Power Of Attorney?:

Have you contacted any other lawyer about your potential claim and, if so:

  • Did the lawyer agree to represent you?
  • Are you still being represented by the lawyer?
  • Are you now seeking a lawyer to represent you, or are you just looking for a second opinion?
  • Do you owe any other lawyer a fee in this matter?
  • If we are willing to represent you, do you wish to employ us?
  • Would you like to arrange a personal interview?

Are there any other questions you wish answered?

Is there any other information that you want to provide us?

Are there any other instructions you wish to give us ?

How did you find our web site?

If you found us through a search engine, which keywords did you use to find us?

Please tell us what you think of our service and any suggestions you have to improve it:


If you are finished, agree with the above, and want to send this information by e-mail:

If you want to start over to correct or change information:

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