AvMA - Online new client form

Contact Name*

Title First name Last name

Address*

Address line 1 Address Line 2 Town County Post code Country

Daytime Phone Number*

Email

Name and Date of birth of the person affected*

(if applicable) Your relationship to the person affected (eg. parent, partner, sibling):

When did the incident occur?*

On what date did you first realise that you or the person concerned had suffered an injury as a result of the incident?*

What is the present condition of the person concerned?*

Hospital(s), Practice involved:*

Doctor(s) or other carer(s) involved:

What are you seeking now? (please tick relevant box(s)

Explanation and/or apology (I have read the AvMA leaflet on making a complaint to the NHS)
Disciplinary action (I have read the AvMA leaflet on health professionals fitness to practice)
Financial recompense (I have read the AvMA leaflet on legal action/ claiming financial compensation)

Please give us an account of events: Include what treatment you received and what happened*

Complaints about treatment

Have you made a written formal complaint?

Yes
No

If yes please give the date complaint made

Have you received any response? (if so please upload a copy of this below)

Yes
No

Your letter of complaint to your Healthcare provider

Max. file size: 1 MB.

The response from your Healthcare provider

Max. file size: 1 MB.

Do you have copies of your medical records?

Yes
No

If no how long have you been waiting?

Has anyone has been assisting you with your complaint? (eg NHS Advocacy, CAB, Healthwatch, CHC, PASS) If yes who?

Have you been in contact with relevant support organisations? If yes who?

Have you previously contacted the AvMA Helpline?

Yes
No

Inquests

In a case involving a death, has the matter been reported to the Coroner?

Yes
No

Is an Inquest to be held and if so please give the date? (or rough date)

Do you require representation or advice on this?

Yes
No

Legal Action

The purpose of litigation is solely for obtaining financial compensation. It does not provide the means of obtaining explanation, apology or disciplinary action against a particular practice.

Bearing these factors in mind do you feel litigation is the appropriate course of action for you?

Yes
No
Dont know

Have you already been in contact with a solicitor?

Yes
No

If yes, please provide us with the name of solicitor and firm:

When did you first instruct a solicitor?

Is your solicitor acting on your behalf.

Yes
No

If not, why?

When did you last have contact with your solicitor?

Are you happy with your present solicitor.

Yes
No

If not, why?

Do your solicitor have a complete copy of your medical records?

Yes
No

Do you or your solicitor require urgent assistance?

Yes
No

If not, why?

Do you want AvMA to?

Signpost you to three specialist clinical negligence solicitors in your geographical area to allow you to contact the solicitor(s) directly
Refer your case to a solicitor by forwarding the information you have supplied to one named solicitor (please note that this is conditional on our Advice and Information Service finding grounds to make such a referral)

To help us improve our service, can we send you a satisfaction survey?

Yes
No

Are you happy for us to email you information about our work and how you can help us? You can unsubscribe at any time.

Yes
No

Privacy notice: The information we send you may include a newsletter to tell you more about the work we do and information about how you can help us including occasional emails about our conferences, events or fundraising. We will always store your personal details securely. To view our privacy notice please visit www.avma.org.uk/privacy

How did you hear of AvMA?

Online new client form

New Client Form

Complaints about treatment

Inquests

Legal Action