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Nursing Home Litigation Form

Nursing Home Litigation Case Form

NOTE:  An Asterisk (*) Indicates REQUIRED Information.

*Full Name:

Home Address:

City:

State:

Zip:

Phone Number:

  

*E-mail Address:
 

What is the name & location of the care facility?


 

When was the patient in question admitted to the facility?


 

Has the patient in question received medical care as a result of the neglect which took place at the facility?


 

What is the name and contact information (including the relationship to the patient) for the primary caretaker?


 

Describe the neglect that took place.


 

Is the patient in question still at the facility?


 
   

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The Miami, Florida, law firm of Panter, Panter & Sampedro, P.A. provides experienced legal advice and representation to injured people from throughout the state of Florida, including South Florida, the Florida Keys, Central Florida, and Northern Florida; Miami Dade, Duval, Leon, Marion, Orange, Hillsborough, Pinellas, Palm Beach, Lee, Collier, Monroe and Broward counties; and cities and communities such as Tallahassee, Jacksonville, Ocala, Orlando, Tampa, St. Petersburg, Clearwater, Fort Myers, Naples, West Palm Beach, Boca Raton, Fort Lauderdale, Hollywood, Miramar, North Miami Beach, Miami Beach, Hialeah, Coral Gables, Coconut Grove, Pinecrest, Kendall, Homestead, Key Biscayne and Weston.