Clinical Negligence Claim

Please complete the details below and we will contact you within 4 working hours of receipt. An appointment will then be arranged for you to be seen by one of our specialist team, in your home, or at one of our offices, at a time convenient to you.

Browell Smith & Co Solicitors
Free Consultation, No Obligation, 100% Compensation.

Your Name

Address

City/Town

County

Postcode

Date of birth

Date of Birth :: Please enter the date in the format DD/MM/YYYY

NI Number

National Insurance Number :: If you can't remember your number, you may find it on official paperwork, eg;
- your end of year tax statement (P60)
- a payslip
- a copy of your annual tax return
Otherwise, contact your local Jobcentre Plus, social security office or HM Revenue & Customs (HMRC) NI Contributions Office.

Telephone No.

Email

Email :: Please enter a valid email address e.g. yourname@service.com

Browell Smith & Co Solicitors
Free Consultation, No Obligation, 100% Compensation.

Details of alleged negligence
(very briefly)

Date of incident

Date of Incident :: Please enter the date in the format DD/MM/YYYY

Where did the incident occur

Incident location :: e.g. name of hospital

Details of injuries
(very briefly)

Details of injuries sustained :: Details of physical/psychological injuries sustained and any treatment subsequently received

Date you thought you might have a compensation claim

Date of claim :: Please insert the date when you believe negligence occurred or when you first had reason to believe there was negligence (if later than the date of incident).

Have you made made a formal complaint
under the NHS complaints procedure?

select... No Yes

What was the outcome?
(very briefly)

Do you believe you are eligable for Legal Aid?
(To find out if you are eligable click here
Community Legal Advice website).

I have checked on the website and am...

select... eligible for Legal Aid not eligible for Legal Aid still unsure

Browell Smith & Co Solicitors
Free Consultation, No Obligation, 100% Compensation.

Source Choose Option Television Advert Radio Advert Newspaper Advert (please specify) Union Referral (please specify) Yellow Pages Mail Shot Respondent Recommendation Former/Existing Client (quote reference) Internet (please specify website/search engine) Other (please specify)

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