Name *
Email *
Phone *
Name of Practitioner, Specialty & Hospital/Practice *
Type of Practitioner * GPSpecialistHospitalOther (ie. Physio, Chiro, etc.)
Describe the negligent treatment *
Date of treatment (if multiple dates please insert the first date) *
Please provide a short description of the injury, adverse outcome or disability *
Have you had treatment for your injuries? If so, what is the nature of the treatment? *
If so, who performed that treatment and where?
Why did you choose Don Cameron & Associates? * Saw an online advertisementSaw a newspaper advertisementKate Williams – Medical Law ConsultantReferred by a friendFormer clientOther
What dates and times are you available for an appointment to discuss your enquiry? *
