Fill and Sign the Personal Injury Medical Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT FIRST CAUSE OF ACTION The plaintiff, ________, as Administrator of the Estate of ________, deceased, alleges against the defendants, ____ Hospital, ____________________, __________________, A, B, and C, as follows: 1. On or about the ______ day of ____________, 20____, ________ underwent coronary bypass surgery at __________ Hospital. 2. On or about this date, while ___________ was under the care of the defendants, said defendants incorrectly or improperly passed an endotracheal tube into ________________’s esophagus. 3. As a proximate consequence of the actions of the defendant ____________, as set forth hereinabove, ____________ suffered deprivation of oxygen - 2 - to her brain for a period of time and a full cardiopulmonary arrest which resulted in her death on the ______ day of ___________, 20____. 4. Plaintiff further avers that the defendants were guilty of negligence in one or more of the following ways: a. Negligently failing to provide _________ with adequate and timely medical care and treatment; b. Negligently failing to attend and treat; c. Negligently inserting or placing an endotracheal tube into ________'s esophagus so as to deprive her brain of oxygen and cause the aforementioned damages; d. Negligently failing to diagnose the incorrect placement of the endotracheal tube and to correct the placement in the trachea before brain damage and death occurred. 5. Further, the defendants, __________________________________, A, B, and/or C, are vicariously liable for the actions of the defendant _________________, who was employed by ___________ Hospital, ____________________, A, B, and/or C, and who was acting as agent of said defendants at the time he negligently rendered care to _____________. WHEREFORE, the plaintiff, ________, as Administrator of the Estate of ________, deceased, demands judgment against the defendants, __________________________________., __________________ A, B, and C, for general damages plus interest and cost. - 3 - Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. ________________________________