Clinical Negligence Enquiry Form

Information about you.

Name

Date of Birth

Home Phone

Work Phone

Mobile Phone

Email address

Information about the incident.

Please provide brief details of the background to your claim.

Please summarise what error you say was made by your doctor/hospital.

Please summarise how you have been injured or suffered because of the above error.

Legal aid

Do you wish to apply for Legal Aid?

Please note that public funding (legal aid) is means tested and generally will only be available to applicants who are in receipt of Income Support/Job Seekers Allowance or otherwise have a low income and limited savings. In cases involving children, however, the means of the child are assessed and not the parent. Children without any independent income, therefore, will generally be financially eligible.

Who is potential claim against?

Please state name of the person or hospital the claim is made against.

Was the treatment provide by the NHS or was it private treatment?
Please provide any other details.