Fill and Sign the Instructions for Completing the Civil Cover Sheet Form

- 1 - IN THE CIRCUIT COURT OF_________ COUNTY, ____________ NAME OF PLAINTIFF ) )) V. ) NO. )) NAME OF DEFENDANT ) )) COMPLAINT I. Plaintiff, _____________________, is an adult resident citizen of _________________,____________ County, ________________. Defendant, __________________ , M.D., is an adult resident citizen of ____________ County, ________________ who may be served with process of this Court at his office located at __________________, _______________________, ________________. Defendant, ____________________, M.D., is an adult resident citizen of ____________ County, ________________ who may be served with process of this Court at his office located at _____________________, ________________________, ________________. II. On or about _________________ _________, 20_____, Plaintiff came under the treatment and care of Defendant ___________________. On or about _____________ ____________, 20____, Defendant __________ performed a surgical procedure upon Plaintiff during the course of which he was injured. III. The Defendants were guilty of negligence and deviated from the standard of care in their examination, treatment, and care of Plaintiff. IV.
As a legal matter, it is undisputed that the injured plaintiff has made factual allegations sufficient to permit this court to enter jurisdiction. (a) factual allegations: 1.   that in the fall of 1999, plaintiff,ana adult resident citizen of county, suffered an injury. 2. That in the fall of 1999, plaintiff suffered the injury at, a hospital in, place unknown, including, ; a surgical procedure upon him. 3. That prior to the procedure, defendant performed a procedure upon plaintiff which involved the operation and treatment of the heart and lungs, blood vessels, sinuses, and throat, without adequate warning to plaintiff. (see: (b) defining “medical treatment or hospitalization" in ().) 4. That the injury, which allegedly occurred at,, , was the result of the negligence of the defendants, who failed to exercise due care and diligence to ensure that the procedure was carried out with adequate protection of health and safety.  (see: (c) defining“"due care" in () and ((e) .) 5. ) that prior to the negligence and operation performed by the defendants, plaintiff was in a state of substantial discomfort, pain, and suffering, which was caused primarily by the negligence of the defendants.  (see: (d) defining“"substantial" in ().) 6. That it was a serious medical emergency that required medical treatment by plaintiff in a hospital or other medical facility. (see: (e) defining “medical treatment" in ().) (d) defining “medical hospitalization" in ().  8. That the injury that theinjuries's plaintiff alleges he suffered at the hospital occurred from the failure of the defendants to provide or administer necessary, proper medical treatment.  (see:)) (ii) facts  of accident: 9.   plaintiff, a citizen of the state in which defendant resides, , was involved in a motorcycle accident on , highway, that resulted in the injury of