12.1 On and after June 25, 1976, any party to any civil action alleging malpractice as defined in 18 Del.C. § 6801(7), at any time after the filing of an answer or any motion filed in lieu thereof, shall have the right to convene a malpractice review panel by filing a demand therefor with the Prothonotary, all parties to the civil action, and the Commissioner. The demand for the convening of such a malpractice review panel shall be in substantially the following form: Name of Case: ____________________ Civil Action No.__________________
The undersigned (name of petitioner), of (city) in (county), being a party to the above civil action alleging malpractice within the meaning of 18 Del.C. § 6801(7), certifies that:
12.1.1 (patient's name) was a patient of (health care provider), on (date); and12.1.2 Said (health care provider), in treating said (patient's name) for (nature of condition or disease), is alleged to have committed an act of malpractice in rendering or failing to render health care services to the injury of (patient's name) in that (short statement of incident and injury); and12.1.3 A complaint and an answer have been filed in the above-mentioned action (or a motion has been filed in lieu of an answer), copies of which are annexed hereto. In consequence thereof, the undersigned petitioner hereby respectfully and in good faith requests that a panel be convened pursuant to 18 Del.C. § 6802 for investigation of this matter.
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Petitioner or Attorney for Petitioner