Tri-State Medical Malpractice Case Form
For New York, New Jersey, and Pennsylvania cases only
Call 516-262-4411
Where did this occur?
New Jersey
New York
Pennsylvania
Type of Medical Incident?
Misdiagnosis or delayed diagnosis
Surgical error
Medication error
Birth injury
Hospital-acquired infection
Other
When did the medical incident occur?
Within the last 6 months
6 months to 1 year ago
1 to 2 years ago
More than 1-3 years ago
Did the medical error result in serious injury or harm?
Yes, significant injury requiring additional treatment
Yes, permanent injury or disability
Yes, loss of limb or amputation
Yes, resulted in death of a loved one
Minor injury or no lasting harm
Did another doctor tell you something was done incorrectly or should have been handled differently?
Yes
No
Have you already spoken with a lawyer about your case?
No, you would be the first
Yes, I'm seeking a second opinion
Yes, but my previous attorney declined my case
Please describe what happened and a DATE when the incident occurred:
Contact Information
First Name *
Last Name *
Email *
Phone *
Submit Case