| If you are unhappy with
your dental treatment and would like an expert
view on whether or not you have the basis for
a legal claim, or you would just like to have
an aspect of your dental treatment checked by
one of our dentally qualified partners then please
fill in our claim check questionnaire below. |
| Completing
our claim check questionnaire does not commit you to starting a legal claim
but does enable you to get access to our specialist
knowledge, and allows us to show you that should
you wish to proceed with a claim, the Dental
Law Partnership is the right choice for your
legal representation. |
| Please complete all the sections as fully as possible as this will help us to
be able to assess your case quickly and accurately. Should you have electronic
copies of documentation, then up to three documents may be attached. Please
note that following our assessment, whatever our advice, we will confidentially
retain this questionnaire and electronic documents for our records. |
| * required |
|
PERSONAL DETAILS |
| Title (Mr, Mrs etc) |
* |
|
| First Name(s) |
* |
|
| Family name |
* |
|
| Address |
* |
|
| Postcode |
* |
|
| Telephone (Home) |
* |
|
| Telephone (Mobile) |
|
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| Telephone (Work) |
|
|
| Fax |
|
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| E-mail Address |
* |
|
As a means of communication are you: |
| Acceptable to receiving text messages? |
|
|
| Acceptable to receiving emails? |
|
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| When would it be convenient to contact you by telephone: |
| Before 9.00am |
|
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| Between 9.00am & 5.00pm |
|
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| After 5.00pm |
|
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| |
|
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Date of Birth
e.g. 31/12/1982 |
* |
day
month
year
|
| Occupation |
|
|
| National Insurance Number |
|
|
Do you receive any social security benefits?: |
| |
| If so please give brief
details. |
|
|
| Do you have Legal Expenses
Insurance Cover? |
|
|
If yes please provide
details:
(please check your household insurance policy provider for cover
for personal injury) |
| |
| Are you a member of a
Trade Union who may fund your case? |
|
|
| DENTISTS DOCTORS
AND HOSPITALS |
| Please note that we will
not, under any circumstances, contact any of
these dentists, doctors or hospitals without
your authority. Please list the dentists, doctors
and hospitals you have received relevant dental
treatment from. |
| Approx Dates |
|
Name and address of Dentist, Doctor,
Hospital etc |
| |
* |
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| |
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| YOUR TREATMENT |
| Please give details of
the dental treatment you are complaining about. |
| *
|
| Please list the dentist(s)
whose treatment you are complaining about and indicate approximately how long you had been their patient |
| *
|
| Why do you think your
treatment was sub-standard? |
| *
|
| On what date was the treatment
in question provided? (please provide at least
the approximate month and year) |
| *
|
| Have you received a refund from your dentist in connection with this treatment? |
|
| Have you instructed other solicitors in connection with this treatment? |
|
| Are you involved in court proceedings in connection with this treatment? |
|
| When did you first realise
there was a problem with the treatment? |
| *
|
| Please briefly set out
how you found out, or were informed, that there
was a problem with your dental treatment. |
| *
|
| Your injury or damage.
Please briefly set out how you have suffered
as a result of the problems with the dental treatment
in question. |
| *
|
| Please tick the appropriate box in respect of the treatment you are complaining about |
|
| Further treatment
costs. Please give details of any
corrective dental treatment you have had or
will require in the future. Include details
of the likely cost and also include an estimate
of how long the treatment will take. |
| *
|
| * How did you find out about
the Dental Law Partnership? |
| Internet |
|
|
|
| |
Please indicate the search engine used |
| |
google
msn
altavista
|
| |
Other
please give details |
| www.askthedentist.info |
|
|
Solicitor |
|
| Dentist |
|
|
Citizen Advice Bureau |
|
| GDC |
|
|
Personal referral |
|
Other
|
please give details |
| |
| FILES TO ATTACH
(optional- max 3 files) |
|
|
| Dlp reference number(if known) |
|
| YOUR DECLARATION |
| I confirm that the information contained
within this questionnaire is true to the
best of my knowledge and belief.
|
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