Medicolegal contact form

Membership number

Medical Council registration number

Date of birth

DD/MM/YYYY

Email address

Telephone number(s)

My query relates to:

Claim
Criminal investigation
Defamation
Ethical/ legal dilemma
Generic medicolegal advice
Inquest
Medical Council issue
Patient complaint
Other

Period of involvement (date of earliest interaction and date of last interaction with patient relevant to the incident giving rise to case)

From

DD/MM/YYYY

Date of the incident

DD/MM/YYYY

Details of the incident

At the time of the incident, what was your Specialty?

At the time of the incident, what was your location?

At the time of the incident, what was your seniority/ grade?

Name of hospital/ clinic

Brief anonymised summary:

Patient initials

Patient year of birth

MM/YYYY

Patient outcome

If applicable, patient date of death

DD/MM/YYYY

If you have documents that you wish to forward us, it is not usually necessary to forward us all the documents now. Please only forward the salient documents, for example:

HPCSA: The HPCSA’s letter informing you of the complaint and the complaint letter.
Request for records: Only the letter from the lawyer requesting disclosure.
Claim: The letter from the lawyer informing you of the claim and the particulars of claim if they have been sent.

Upload files:

Permissible formats: jpg, jpeg, png, gif, bmp, pdf, doc, docx, ppt, pptx, ppsx, xls, xlsx

Please confirm the following:

I confirm that I have not included any information that would allow a patient to be identified

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