__[Attorney name]__
__[Address]__
__[Telephone number]__

Attorney for Plaintiff
__[name]__

            _ _ _ _ _ _ Court, County of _ _ _ _ _ _
                   __[_ _ _ _ _ _ District]__

_ _ _ _ _ _ _ _ _ _ _ _ _  )   No. _ _ _ _ _ _
                               Plaintiff(s))
vs.                                                        )NOTICE OF INTENTION TO
                                                                          )COMMENCE ACTION
_ _ _ _ _ _ _ _ _ _ _ _ _  )
                               Defendant(s))
_________________________  )

To __[name of health care provider]__:
     PLEASE TAKE NOTICE that __[name(s) of plaintiff(s)]__
intend(s) to commence an action against you as a defendant, based
on your professional negligence, 90 or more days from the date of
this notice.  The action will be based on allegations that you
and other defendants negligently diagnosed and treated __[name(s)
of plaintiff(s) or decedent]__, causing bodily injury __[and
death]__.
              [Specify for each injured plaintiff]
     At the present time, the injuries to __[name of plaintiff]__
include: __[Specify nature of injuries]__.
     Detriment and loss sustained by __[name of plaintiff]__
include:
     1.   Medical and related expenses __[in the amount of $_ _ _
_ _ _/in an amount over $_ _ _ _ _ _/in an amount not yet fully
ascertained]__  __[plus expenses reasonably certain to be
incurred in the future]__.
     2.   Impairment of earning capacity __[in the amount of $_ _
_ _ _ _/in an amount over $_ _ _ _ _ _/in an amount not yet fully
ascertained]__  __[plus loss reasonably certain to be incurred in
the future]__.
     3.   Loss and expense of services __[in the amount of $_ _ _
_ _ _/in an amount over $_ _ _ _ _ _/in an amount not yet fully
ascertained]__  __[plus loss reasonably certain to be incurred in
the future]__.
     4.   Pain, suffering, emotional distress, and impairment of
enjoyment of life.
                      [Add if appropriate]
     5. Detriment and loss sustained by __[name of plaintiff's
spouse]__ include loss of consortium.
                     [Add for each decedent]
     [6.] Detriment and loss sustained by __[names of decedent's
heirs]__ include __[e.g., loss of financial support, services,
contributions, gifts, society, comfort, companionship, care,
training, and advice]__ from __[name of decedent]__, plus funeral
and burial expense in the amount of $_ _ _ _ _ _.
                           [Continue]

Date: _ _ _ _ _ _                                          [Signature]
                                                                                                         _________________________
                                                                                                                                            __[Typed name]__
                                                                                                         Attorney for _ _ _ _ _ _ _ _ _ _
      


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Legal Forms : Set Two