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New enquiry: Clinical/Medical Negligence enquiry
Please fill in the Questionnaire below:
1. Personal Details
Surname/Company Name
House
Area
Postal Town
County
Postcode
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2. Injury Details
Injury Sustained Description
Time Off Period
Hospital Name
Please state what medical advice/assistance you ha
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3. Negligence Details
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Date of negligence
Time of negligence
Please state what medical advice/assistance you ha
Brief details of negligence and who was to blame
4. Witnesses Details (including details of others injured, or have been injured at same place)
Witness 1 Details
Witness 1 Title
Witness 1 Initials
Witness 1 Forename
Witness 1 Surname
Witness 1 Address
5. Is there any other information that you consider may be relevant?
Any Further Information
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