Medical negligence claim - enquiry form

If you or a loved one have been injured or suffered as a result of what you believe to be negligent medical treatment complete the claim form below and a member of our leading team of medical negligence specialists will contact you to discuss your claim for compensation. Alternatively you can call us on 0161 696 6165.

Title

Please select your title

First name Please enter your first name

Surname Please enter your surname

Date of birth of injured person Please enter date of birth of injured person

Address Please enter your address

Postcode Please enter your post code

Telephone Please enter your phone number

Mobile Please enter your mobile number

Email Please enter your email

Did the negligence occur in England or Wales?

Date of negligent treatment Please enter the date negligence happened

Confirm date injured party become aware of the negligence Please enter date you became aware of negligence

What injury have you suffered as a result of the alleged negligence? Please confirm type of injury

Has person suffered loss of earnings - if so please provide approximate value Please confirm loss of earnings

Additional information, including what you think was negligent about your treatment and whose fault it was: Please enter any additional information

Did the negligence result in death?

Preferred contact method

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Preferred contact time

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How did you hear about us?

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