Fill and Sign the Complaint Petition or Declarationfor Negligence in Permitting Fall of Aged Patientwrongful Death Form

IN THE ________________ COURT OF _________________ (County), _______________________ (State) _____________________________ PLAINTIFF(Name of Plaintiff)V. CAUSE NO. __________________________________________ DEFENDANTS_____________________________ _____________________________ (Names of Defendants) COMPLAINT COMES NOW _____________________________ (Name of Plaintiff), Plaintiff in the above-styled and numbered cause, by and through his attorney, and files this Complaint against Defendants, _____________________________________________ ____________________________ (Names of Defendants), and in support thereof would show unto the Court the following matters and facts: I. Plaintiff is an adult resident citizen of ___________________________________ ______________ (city, county, state).II.Defendant Alpha is a corporation organized and existing under the laws of the state of ______________, with its principal office located at ______________________ ______________________________________________________________________ (street address, city, county, state, zip code), referred to herein as Defendant Alpha and may be served with process by serving its agent for service of process ______________________________ (Name) located at _________________________ ______________________________________________________________________ (street address, city, county, state, zip code.III. Defendant Beta is an adult resident citizen of ____________________________ _____________ (city, county, state) .IV. Defendant Zeta is an adult resident citizen of ____________________________ ______________ (city, county, state).V. At all times referred to herein, Defendant Beta and Defendant Zeta were employees of Defendant Alpha and under its direct supervision and acting within the scope of their responsibilities and duties with said Defendant Alpha. VI.On _________________________ (date of injury), at about _____________ (time of injury), Defendants Beta and Zeta were dispatched in an ambulance owned and operated by Defendant Alpha to the home of Plaintiff where he had (reason for ambulance being dispatched) ____________________________________________ ______________________________________________________________________. VII.While attempting to place Plaintiff on a gurney, Defendants Beta and Zeta negligently dropped Plaintiff causing Plaintiff to suffer a broken back (might describe in more adequate medical terms) ___________________________________________.VIII.Plaintiff's injuries were proximately caused by the carelessness and negligence of Defendants Beta and Zeta, agents of Defendant Alpha.IX. Defendants Beta and Zeta were not trained paramedics and this lack of training was known by Defendant Alpha. X. As a further direct and proximate result of having sustained the above-mentioned injuries, Plaintiff was obliged to incur expenses for X-rays, medical care, medicines, hospital care, and nursing care.XI. As a further direct and proximate result of having sustained the injuries, Plaintiff endured great pain and suffering, loss of sleep and appetite and was in a habitual nervous condition.XII. Plaintiff's injuries are of a permanent and lasting nature.WHEREFORE, Plaintiff requests judgment against Defendants, jointly and severally:1. In the amount of $______________, as damages;2. Awarding Plaintiff the costs of this action; and3. Granting Plaintiff such other and further relief as the Court deems just and proper. Respectfully Submitted,_____________________________ Name of Plaintiff By: __________________________ Name of Attorney Bar No. ________________ Of Counsel:Attorney for Plaintiff Post Office Box _______________________________________________________(City, State, Zip Code)Telephone: ____________________