Medical Malpractice Questionnaire -- Law Offices of Howard A. Kapp

3731 Wilshire Blvd., Suite 514, Los Angeles, California 90010 * (213) 927-8000 * staff@kapplaw.com

Litigation Boutique

Law Offices of Howard A. Kapp

Very Brief Description of your Case *

Please explain how the victim was hurt (and continues to be hurt) as a result of the malpractice. Please include a good description of any physical or mental injuries, as well as any economic losses (such as wage loss or need for additional care. If the victim died as a result of the malpractice, tell us about the relationship he or she had with each of her legal heirs (potentially, parents, spouse, children, etc.).

What is the date of birth of the injured person? If you are not sure, put in your best estimate and let us know below. *

Legal Stuff We Are Required to Tell You: Your filling out this form does not make the Law Offices of Howard A. Kapp your lawyers or responsible for any deadlines. Mr. Kapp is only responsible if he tells you that he has accepted your case, supplied you with a retainer contract and you have signed and returned it.

We try to respond to these types of inquiries within 1 or 2 business days. If you believe that you need faster service, please call our office at (213) 927-8000 during regular office hours.

We are sorry that this form contains so many questions, but medical malpractice cases tend to be far more involved than other personal injury cases. So please help us help you!

Please note that we cannot take cases outside of California, except on referral from another lawyer.

Cases where the malpractice occurred more than 1 year ago may be untimely. If the malpractice occurred more than 1 year ago, please explain why no lawsuit has been filed; otherwise, you may skip this question.

Please give the LOCATION of the malpractice (please at least include the CITY or town where the malpractice occurred). *

Name of the Injured Party *

Please explain WHY the victim was treating with the doctor(s) you want to sue (include the symptoms (complaints) or diagnosis). *

Please include the following information:about the victim (1) his or her age (and any specific health issues BEFORE the malpractice), (2) marital status (if married, give us a few details), (3) educational background, (4) recent employment background and (5) anything else we should know about the victim's life BEFORE the malpractice.

Upload Any Materials You Want Us to Review (This does NOT make us your attorneys or responsible for your case).

Please give the date you discovered the malpractice (Mandatory if the doctor's malpractice occurred more than 6 months ago)

Date of the Malpractice (if this malpractice took a long time, give the last date of any acts of malpractice) *

Name, Address and Daytime Phone No.:of the Person Submitting This Inquirty *

Email: *

Please describe what happened and why you think that you might have a case to sue. Please discuss what the provider(s) did wrong; you can discuss the victim's injuries and losses belowl *

3731 Wilshire Blvd., Suite 514, Los Angeles, California 90010 * (213) 927-8000 * staff@kapplaw.com

Law Offices of Howard A. Kapp

​Send a Detailed Description of Your Case to the Law Offices of Howard A. Kapp regarding your Medical Malpractice Claim

Send a Detailed Description of Your Case to the Law Offices of Howard A. Kapp regarding your Medical Malpractice Claim