Medical Malpractise Case Consultation Request Form

Medidcal Malpractise

First Name

Last Name

Phone/Mobile

Country

Date of birth

Current residency status

Registered foreigner — currently in Korea (holds ARC, residing in Korea)

Registered foreigner — currently abroad (holds ARC, but currently outside Korea)

Unregistered foreigner — currently in Korea (in Korea without ARC)

Unregistered foreigner — currently abroad (outside Korea, no ARC)

Korean national

Name of hospital / clinic

Location of facility (approximate area is fine)

Department / specialty

Date of procedure / incident

Date of first visit

Purpose of visit

Medical treatment

Cosmetic / aesthetic

Health check-up / screening

Other

If other, please specify.

Chief complaint or cosmetic goal at the time (before treatment)

Name of procedure / surgery / treatment received (to the best of your recollection)

Current symptoms or outcomes you consider problematic (complications, worsened condition, deformity, etc.)

Have you received follow-up treatment or revision surgery at the same or another facility?

If yes, name of the facility(ies) (optional)

Were you given adequate verbal or written explanation of the risks and potential complications before the procedure?

Yes, fully explained

Partially explained

No explanation given

Unsure

Did you sign a consent form or information sheet? Do you have a copy?

Yes, signed — and I have a copy

Yes, signed — but I do not have a copy

No consent form was presented

Unsure

Documents and evidence currently in your possession (check all that apply)

If other, please specify.

Please describe the losses or harm resulting from this incident

Have you already filed or inquired about any of the following?

Criminal complaint against the medical professional

Mediation application with the Korea Medical Dispute Mediation and Arbitration Agency (KMDMAA / 한국의료분쟁조정중재원)

Civil lawsuit

Complaint to the health authority

None yet

What outcome are you seeking? (check all that apply)

Monetary compensation / damages

Formal apology from the medical provider

Corrective or revision surgery

Criminal liability of the medical professional

Other

If other, please specify.

Type of legal action you are considering

Civil lawsuit (damages claim)

Criminal complaint

Mediation / arbitration

Not yet decided — seeking advice

Any other information you would like us to know

Medical Malpractise Case Consultation Request Form

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