Medical Negligence Form

Your Full Name*

DoB* (dd/mm/yyyy)

Address*

National Insurance Number

Occupation

Email*

Telephone Number

Name, Date of Birth and Address of Patient (if you are not the patient)

How did you find us?

1. Name& Address of GP Practice of Patient & name of any hostpital(s) attended.

2.(a) What treatment do you think was negligent, (b) where did that negligent treatment happen and (c) when did that negligent treatment happen?

3. What injuries / symptoms have you suffered because of the negligent treatment?

4. When and how did you first become aware of the negligent treatment?

Have you gone through any Complaint / NHS Internal Complaints Procedure?

yes no

If Yes please email a copy to info@peacockjohnston.co.uk

Personal Data

Peacock Johnston observes the legislative obligations and Law Society of Scotland rules and recommendations in their control and processing of personal data. Anyone submitting any enquiries by e-mail acknowledges and explicitly consents to the processing of that data for the purposes of dealing with client enquiries and/or instructions in respect of legal services.

Contact Us

Affordable Specialists Who Understand

Medical Negligence Form

0141 333 9505

enquiries@peacockjohnston.co.uk

info@peacockjohnston.co.uk