Registration form
Medico-legal expert opinion

  Personal data of Sender:
  Name:
  First name:
  Title:
  Address:
  phone:
  fax:
  e-mail:
  At this initial phase, I prefer to keep the identity of my relative anonymous
  Optional personal data of your relative:
  Name:
  First name:
  Title:
  Address:
  phone:
  fax:
  e-mail:
 

 

 

Compulsory data of your relative for initial evaluation procedure:
  Age:  
  Sex: f m  
     
 

Previous diseases of your relative:

Year: diagnosis (operation)
     
     
Did your relative suffer a damage from surgery? yes  no 
  from other treatment? yes  no 
  from an accident? yes  no 
If applicable, date of damage:
Are all medical documents available? 
(patient record, x-rays, reports)		 yes  no 
 
Name of relative's attorney :  
Your relative's opponent in a legal proceeding:   
     
legal proceedings : not yet   
  underway since:  
 

finished since :

 
 

Other explanations: 


  
     
 

 

Short description of events:

  
 

 

Short description of consequences until today:

  

In case you can not send this form, please give us a call at (212) 231-8443
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