Exercise Extreme Caution when using many of our free forms - or any legal material. While they may provide general ideas on format & content, validity requirements can and do vary greatly from state to state. Many MUST be Properly Modified for your own location and circumstances. (Hint: If in doubt it's usually safer to include unneeded clauses than to leave out necessary ones. . . . but it's even safer to consult a competent source or use current, state specific ones like ours mentioned below.) Also, we urge people (and lawyers too) to read our Relying On Legal Info FAQ.

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[Attorney name]
[Address]
[Telephone number]

Attorney for [e.g., Defendant], [name]

xxx Court, County of xxx
[xxx District]

xxxxxx ) No. xxx
Plaintiff(s) )
vs. ) DEFENDANT'S SEPARATE
) STATEMENT OF UNDISPUTED
xxxxxx ) MATERIAL FACTS
Defendant(s) )
_________________________________) Hearing: [date; time]
Department: xxx
Trial Date: [if set]

Defendant, [name], in support of his motion for summary judgment or summary adjudication of issues, submits that the following material facts are undisputed in this action:

ISSUE NO. 1

1. The alleged acts of medical malpractice on which plaintiff [name]'s first cause of action is based occurred on or before March 3, 1994.

SUPPORTING EVIDENCE:

a. Plaintiff's second amended complaint at p 3, paragraph 5, lines 15-23.

b. Plaintiff's answers to requests for admissions, answer no. 8 at p 3 (copy attached as Exhibit E to defendant's declaration).

2. Plaintiff became aware of defendant's alleged medical malpractice, and of all injuries allegedly sustained as a result, on or before March 12, 1994.

SUPPORTING EVIDENCE:

a. Plaintiff's answers to requests for admissions, answer no. 14 at p 3 (copy attached as Exhibit E to defendant's declaration).

b. Transcript of plaintiff's deposition at p 13, lines 5-8 (signed original attached).

3. This action was commenced on the filing of plaintiff's original complaint on April 1, 1995.

SUPPORTING EVIDENCE:

a. Filing stamp affixed to plaintiff's original complaint in this action, of which the Court is requested to take judicial notice.

ISSUE NO. 2

4. Plaintiff was fully informed regarding the consequences and complications that could result from the surgical procedure.

SUPPORTING EVIDENCE:

a. Defendant's declaration at p 3, line 20.

b. Transcript of plaintiff's deposition at p 7, lines 13-16 (signed original attached).

5. Plaintiff verbally expressed his understanding of the consequences and complications that could result from the surgical procedure.

SUPPORTING EVIDENCE:

a. Defendant's declaration at p 3, lines 10-17.

b. Transcript of plaintiff's deposition at p 8, lines 3-8 (signed original attached).

6. Plaintiff read, dated, and executed a form entitled "Consent to Surgery--Binding Waiver of Liability," which included the following language: "I have discussed with my doctor in considerable detail the nature, extent, and dangers of the surgery to be performed, as well as the possible consequences, complications, and side effects of that surgery, all of which I fully understand. I still want the surgery. I do NOT want a second opinion."

SUPPORTING EVIDENCE:

a. Copy of form, attached as Exhibit F to defendant's declaration.

b. Defendant's declaration at p 3, lines 14-18.

c. Plaintiff's answers to requests for admission, answer no. 13 at p 4 (copy attached as Exhibit E to defendant's declaration).

7. Plaintiff read, dated, and executed this form after having been fully informed regarding the consequences and complications that could result from the surgical procedure.

SUPPORTING EVIDENCE:

a. Defendant's declaration at p 3, lines 1-3.

b. Plaintiff's answers to requests for admissions, answer no. 14 at p 4 (copy attached as Exhibit E to defendant's declaration).

ISSUE NO. 3

8. Plaintiff did not sustain any loss of wages.

SUPPORTING EVIDENCE:

a. Plaintiff's answers to requests for admissions, answer no. 3 at p 1 (copy attached as Exhibit E to defendant's declaration).

Date: xxx ______________________________
[Typed name]
Attorney for xxxxxx

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