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Name

Phone Number

Email Address

Approx. Date of Treatment

When did you become aware you may have been injured due to negligence?

Location of treatment Location of treatment Hospital GP Practice Care Home Other

Briefly insert details of your claim or injury

Briefly describe any pre-existing health conditions

Have you experienced any of the following? Have you experienced any of the following? Physical Pain Mental Disorder Treatment/Equipment Costs Lost Work/Earnings Care/Support at Home Required?

Employment Status Employment Status Unemployed Employee Self-employed Student

Have you made a subject access request for clinical records? Have you made a subject access request for clinical records? Yes No

Name

Phone Number

Email Address

Approx. Date of Treatment

When did you become aware you may have been injured due to negligence?

Location of treatment Location of treatment Specialist Dental Hospital/Clinic Dental Practice Orthodontist Other

Briefly insert details of your claim or injury

Briefly describe any pre-existing health conditions

Have you experienced any of the following? Have you experienced any of the following? Physical Pain Mental Disorder Treatment/Equipment Costs Lost Work/Earnings Care/Support at Home Required?

Employment Status Employment Status Unemployed Employee Self-employed Student

Have you made a subject access request for clinical records? Have you made a subject access request for clinical records? Yes No