Intake Lakeland LawsuitBradshaw Law Office2025-04-18T03:13:58-05:00 Contact InformationName(Required) First Last Phone(Required)Email(Required) Relationship to PatientI am the(Required) Patient Parent/Legal Guardian Other Patient's Full Name:(Required) First Last Patient's Date of Birth:(Required) MM slash DD slash YYYY Lakeland Stay Details * Approximate dates at Lakeland:*Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY * Type of Incident(s):(Required) Abuse by staff member Abuse by another patient Neglect/lack of supervision Other misconduct When did the incident(s) occur?(Required) During the stay listed above Multiple times during stay Specific date Date MM slash DD slash YYYY Additional InformationDisclaimers(Required) I consent to receive text messages from Brad Bradshaw M.D. J.D. L.C.. Messages sent may include Customer Support, Legal Updates for Clients, Appointment Scheduling, Appointment Reminders, and message frequency will be based on client interactions, appointment schedules, or as updates arise. Message and data rates may apply. Reply HELP or contact us at info@bradbradshaw.com for support. Reply STOP to opt out of future messages at any time. Read Privacy Policy and Terms of Use.
