Client Intake Form

Please select your incident:

Catastrophic Injury
Medical Malpractice

Full name:

Address:

Home Phone:

Business Phone:

Cell Phone:

Fax (if available):

Email Address:

OHIP Number:

Names of Immediate Family Members:

Please provide as much detail as possible:

When did the event (injury) occur?

Where did the event (injury) occur?

Please describe the event and the resulting injuries:

Please identify the health care professional(s) who you think acted inappropriately: