bios





tjsaye@salvilaw.com




(877) 249-1227




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Saturday:
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Sunday:
Closed



Quick Contact

  HEALTHCARE NEGLIGENCE EVALUATION FORM
 
 
First  Name:
Last Name:
Email Address:
Phone: - -
Street Address:
Address #2:
City:
State/Zip: /
What is the best way to reach you?
Please provide the best place, time and method for contacting you.
If you are NOT inquiring on your own behalf, what is your relationship?:
Is the person deceased? Yes No
If deceased, the cause of death
 as stated on the death certificate:
Date of Death:
Please give us a general idea when (month/year) the procedure, surgery or treatment occurred:
Please tell us what medical procedure was being performed and why the treatment was prescribed/recommended:
What injuries did you sustain that you believe are a result of malpractice?
Is an attorney currently representing you for this matter? Yes No
How did you hear about us?
I understand that by submitting this form I am not retaining a lawyer.
Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal "retainer agreement."



 


   
   
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Areas We Serve: Chicago, Aurora, IL, Lake County, Cook County, IL, Joliet, IL, Naperville, ILWaukegan, IL,   Rockford, IL, Chicago, IL, Rock County,  Illinois, Greene County, IL. Our Practice Areas: Medical Malpractice, Personal Injury, Birth Injury, Vehicle Accidents, Nursing Home Neglect, Misdiagnosis.