Medicolegal Case (MLC) Registration Form

Patient Full Name: __________________________

Age / Sex: __________________________

Date & Time of Arrival: __________________________

Incident Description (as per patient or bystander):

[Write description here]

Injury/Complaint Type (tick one):

[ ] Road Traffic Accident [ ] Assault [ ] Burn [ ] Suicide Attempt [ ] Other: ____________

Clinical Summary on Arrival:

[Write summary here]

Examination Findings:

[Write findings here]

Doctor’s Initial Impression:

[Write impression here]

Injury Grading (if applicable): __________________________

Time of MLC Registration: __________________________

Name & Signature of Registering Doctor: __________________________

MLC Number: __________________________

Hospital Stamp / Seal: __________________________

Police Intimation: [ ] Yes [ ] No If Yes, Time: __________ Officer Name: __________

Attachments:

[ ] Photograph [ ] Consent Form [ ] Police Acknowledgment [ ] Other: ____________