THE BENNETT LAW FIRM, P.C. Attorneys and Counselors at Law Robert S. “ Bob” Bennett Board Certified in Consumer Law Texas Board Of Legal Specialization Fellow–College of the State Bar of Texas Email: bennett@bennettlawfirm.com Renée E. Moeller Email: moeller@bennettlawfirm.com 515 Louisiana, Suite 200 Houston, Texas 77002 Tel: (713) 225-6000 Fax: (713) 225-6001 Website: www.bennettlawfirm.com Steve D. Peterson  Of Counsel Former General Counsel To the State Bar of Texas R. P. “Skip” Cornelius Of Counsel Board Certified in Criminal Law Texas Board of Legal Specialization PHYSICIAN CLIENT INTERVIEW FORM To Be Used with Complaint Before the Texas State Board of Medical Examiners (TSBME) Notice To Physician Client:  All the information you will provide is confidential.  It will not be shown or revealed to anyone without your permission.  If you need more space for any answer please use the back of the attached sheets, or include at the bottom of the form ____________________________________________________________________ NAME:_____________________________    MEDICAL LICENSE NO.________________ COMPANY:  ______________________________ Referred by :______________________ BUSINESS ADDRESS: ______________________________________________________                                    ______________________________________________________ HOME ADDRESS: __________________________________________________________                              __________________________________________________________ TELEPHONE: (HOME)_____________ (WORK)___________ (MOBILE)_______________ E-MAIL ADDRESS: __________________________________________________________ 1. PERSONAL DATA A. DATE OF BIRTH: _________________________________________ (AGE:_________ ) B. CHILDREN: _____________________________________________________________   C. EDUCATION: ____________________________________________________________   D. EMPLOYMENT HISTORY:  ________________________________________________   E.  CLAIMS HISTORY (other claims made against you in Texas or in another  jurisdiction):   __________________________________________________________________________ F.  MARITAL HISTORY:______________________________________________________ G.  PRIOR ARRESTS OR CONVICTIONS       (In any State or Federal Court, include misdemeanors and DWIs): _________________________________________________________________________ H.  MEDICAL LICENSES (Please lists all states in which you are licensed to practice law): _________________________________________________________________________ I.  TEXAS STATE BOARD OF MEDICAL EXAMINERS CERTIFICATIONS: _________________________________________________________________________ 2.  ABOUT THE COMPLAINT A. WHEN DID THE ALLEGED VIOLATION OCCUR? _____________________________ B. WHAT DOES THE COMPLAINANT CONTEND THAT YOU DID WRONG? _________________________________________________________________________ C.HAVE YOU CONTACTED ANY ASSISTANCE PROGRAMS? _________________________________________________________________________ D. WHAT ADDITIONAL INFORMATION WOULD YOU LIKE US TO KNOW      ABOUT THE ALLEGED VIOLATION? _________________________________________________________________________ _________________________________________________________________________   (Attach Copy of Complaint, Response to Complaint, & any other Documents pertaining to the Complaint if mailed or faxed to our office) SUMMARY OF WHAT DOCUMENTS YOU NEED TO PROVIDE A.  Any Grievance Forms and related Documents from the Texas State Board of Medical Examiners and from your Former Patient B.  All Correspondence (Letters and Emails) sent to and received from your Former Patient C.  All Documents from any Hospital or Clinic involved D. All Correspondence (Letters and Emails) sent to and received from TSBME