MEDICAL MALPRACTICE INQUIRY FORM

You may Email by clicking on the submit button below or print this form to mail or fax to us:

Burkhalter, Rayson & Associates, P.C.

P.O. Box 2777

Knoxville, TN 37901-2777

Fax No.: (865) 524-0172

To request more information, please complete the form below.
*Bold fields are required*

*Email:*

*Your Name:*

*Date*

*Date of Malpractice:*

Who are the responsible parties (who you are complaining against)? (This name can be withheld at this time, if you prefer.)

*Why do you think they are responsible?*

*Why do you believe this is malpractice? Please explain.*

*Complaint description:*

*Have any medical providers told you they believe this is a case of medical malpractice? If so, who, when, and what did they say?*

*Where did this malpractice occur? (City, county, and state)*

*What were the injuries caused by this malpractice? Please describe.*

*Who has treated you for these injuries, and what is the approximate amount of the medical bills?*

*Will you have permanent injuries as a result of the medical malpractice? If so, please describe.*

*Approximate amount of losses caused by the malpractice?:*

Other pertinent information:

*When is the best time to contact you, and how would you prefer we contact you?*

*Your home phone:*

Your Work Phone:

Other phone:

*Mailing address ( street, city, st, and zip ):*

When and how did you hear about us?

Your information is being sent directly to Burkhalter, Rayson & Associates, P.C., and by law, all communications to us are 100% confidential.

*There is no charge for us to review this inquiry and on most cases, we do not get paid unless we win.