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Home
About Us
Meet our Partners
Type of Accident
Accidents at Work
Road Traffic Accidents
Trips & Slips
Criminal Injury Claims
Clinical Negligence
Dental Negligence
Product Liability
Type of Injury
Back Injury Claims
Head Injury Claims
Facial & Dental Injury Claims
Fractures & Soft Tissue Injury
Post Traumatic Stress
Spinal Injury Claims
Whiplash Injury Claims
Compensation Calculator
Cycling Accidents (Cycle Aid)
Cosmetic Negligence
Types of Surgery
Contact Us
Cambridge
London
Manchester
Preston
Cosmetic Negligence Claims Form
Cosmetic Negligence Form
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Surname
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First name
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Title
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Address
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Occupation
(*)
Please enter your occupation or 'n/a' if not applicable
National Insurance No
Please enter your national insurance number or 'n/a' if you don't remember yours
When did you first become ill?
(*)
Please let us know a rough date of when you first became ill
What were your symptoms?
(*)
Please let us know your symptoms
When did you seek medical advice?
(*)
Please let us know the date you saught medical advice
From whom did you seek medical advice?
(*)
Please let us know where you received medical advice/treatment
In your opinion, how did the alleged negligence occur?
(*)
Please let us know how the negligence occured
What exactly happened?
(*)
Please let us know what happened
Have you recovered from your illness?
(*)
Please let us know if you have recovered from your illness
If so, how long did you suffer from your symptoms?
Have you returned to work? If so, on what date?
(*)
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Name of GP & Address
(*)
Your GP's name Name of Surgery Address of Surgery Telephone of Surgery
Please enter your GP's details
Name & address of hospital you attended
Name of hospital Hospital Address Hospital Telephone number Hospital Record number (if known) Name of Doctor/Consultant attending you
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Treatment received to date
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Details of your current symptoms
(*)
Please let us know your current symptoms
Was the treatment private or on the NHS?
(*)
Please let us know if this was private or NHS treatment
If privately, with whom are you insured?
Name Address Policy Number
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How did you hear of Simon A Holt & co?
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Do you have any legal expenses insurance as a part of any home contents or building insurance?
(*)
If so, please check your policy and let us have details.
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