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MEDICAL ERROR SUBMISSION

Tell us about a medical error that occurred to you or a family member.

Who did the error happen to?

 You Your family member A friend Other

Were the details of the error disclosed to you by the hospital or doctor?

 Disclosed Y/N:

Please summarize your medical error and the outcome:

Tell us how to get in touch with you:

Name
E-mail
Tel
FAX
Check here if you are willing to publish your story in the future.

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Revised: July 29, 2008 .