Fill and Sign the Medical Complaint Form

- 1 - IN THE CIRCUIT COURT OF_________ COUNTY, ____________ PLAINTIFF ) ) ) V. ) NO. ) NAME OF DEFENDANTS ) ) ) AMENDED COMPLAINT COMES NOW Plaintiff, ________________, through counsel, and files this, her Amended Complaint against the Defendants, ________________ and ________________ to-wit: 1. Plaintiff is an adult resident citizen of ________________ County, _______________. 2. Defendant, ________________, is a hospital organized and existing under the laws of the State of ________________ through its physicians, staff, agents, servants, employees and representatives, who may be served with the process of this court by serving its Administrat or, ________________________________ at ________________________________. Defendant, ________________, is an adult resident citizen of the ______ Judicial District of ________________ County, ________________, who may be served with the process of this Court at her place of employment, ________________________________ at _______________. Defendant, ________________, is liable and responsible for all of the actions, omissions and negligence of its agents, servants, representatives and employees. Defendant, ________________, is a hospital catering to the general public and particularly the Plaintiff offering general medical treatment, room and board, laboratory and technical services toge ther with surgery, emergency room facilities and outpatient treatment. 3. That on or about ________________, Plaintiff sought treatment at the emergency room of Defendant, ________________, complaining of an injury to her left foot; that an x-ray was taken of Plaintiff's left foot and improperly read by Defendant, ________________, and the agents of Defendant, ________________, causing Plaintiff to sustain irreparable injury to her foot and causing her to sustain personal injuries. That by failing to properly diagnose Plai ntiff's fracture, Defendants violated the acceptable standard of care which was the proximate cause of Plaintiff's injuries. - 2 - 4. That at all times mentioned herein, the Defendant, ________________, including emergency room physicians, nurses, aides, technicians and others assisting were the agents, servants and employees acting within the scope of their employment of the Defendant. That through their obvious misdiagnosis, negligence and/or neglect, proximately caused or contributed to Defendant's injury becoming more severe and sustaining unnecessary injuries and damages. That as a result of the negligence of the employees/agents of Defendant, ________________, and specifically ________________, M.D., and her failure to provide appropriate treatment, care and diagnosis and her breach of the applicable standard of ca re and other contemporaneous acts, the Plaintiff was substantially damaged. 5. Plaintiff would further assert that Defendants failed to follow medically accept ed procedures to lessen Plaintiff's injuries. 6. Plaintiff would state unto the Court that the Defendants grossly and negligently failed to properly diagnose, observe, treat, and/or administer proper medical care to Plai ntiff which was the proximate cause of Plaintiff's injuries. 7. Plaintiff would further show that the Defendants are liable and responsible on the basis of res ipsa loquitur and for breach of contract. 8. Plaintiff would show unto the Court that as a direct and proximate result of the negligent actions of Defendants, Plaintiff was caused to endure physical pain and discomfort, mental anguish, needless surgery, permanent disability and was otherwise damaged. 9. That as a direct and proximate consequence of the Defendants' actions, inactions and negligence, Plaintiff alleges that the following damages are recoverable of, from a nd against the Defendants' as follows, to-wit: A. All medical and hospital expenses incurred as a result of the Defendants' negligence; B. Pain and suffering; C. Mental and emotional distress; D. Loss of Wages; WHEREFORE, PREMISES CONSIDERED, Plaintiff, ________________, brings this action against the Defendants, ________________ and ________________, jointly and severally, and demands judgment of, from and against the Defendants in an amount in exc ess of $________________, together with all costs herein. This, the ____ day of __________________, A.D., 20___. - 3 - Respectfully submitted, ________________________________ PLAINTIFF DEMANDS TRIAL BY JURY