qualify for a lawsuit from DPT vaccine damages? Please complete our no
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and DPT vaccine experts are standing by to assist you.
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State / Zip:
(ex. NY / 10005)
Injured Person Information:
Date of Birth:
are you inquiring about?
If you are NOT
inquiring on your own behalf, what is your
Is the person deceased?
If deceased, the cause of death
as stated on the death certificate:
Date of Death:
Was there an autopsy
child had any of the following vaccinations:
Dates that Vaccine(s) were given?
Did child's behavior regress after receiving
If yes, please
describe regressive behavior:
List name and address of Doctor's that
gave DPT Vaccine(s):
List name and address of hospital where
DPT Vaccine was given:
Were any of the following conditions
diagnosed after receiving DPT Vaccine:
Other problems associated with DPT
Do you currently have an attorney who represents you on your