Do you
qualify for a lawsuit from DPT vaccine damages? Please complete our no
obligation, free consultation form. Lawyers familiar with DPT vaccines
and DPT vaccine experts are standing by to assist you.
* Required Fields.
** Click on the
"Disclaimer" link below for Terms
Title*:
First Name*:
MI
Last Name*:
E-mail Address*:
(ex. johndoe@anywhere.com)
Home Phone*:
(ex. 505-555-5005)
Work Phone:
(ex. 505-555-5005)
Mobile Phone:
(ex. 505-555-5005)
Street Address:
City:
State / Zip:
/
(ex. NY / 10005)
Injured Person Information:
Date of Birth:
For whom
are you inquiring about?
If you are NOT
inquiring on your own behalf, what is your
relationship?
Is the person deceased?
Yes
No
If deceased, the cause of death
as stated on the death certificate:
Date of Death:
Was there an autopsy
performed?
Yes
No
n/a
Drug Information
Has your
child had any of the following vaccinations:
Tetanus
Pertussis
Measles
Mumps
Rubella
Polio
Hepatitis
B
Rotavirus
Dates that Vaccine(s) were given?
Did child's behavior regress after receiving
vaccines?
Yes
No
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:
Shock:
Yes
No
Brain Damage:
Yes
No
Encephalopathy:
Yes
No
Metal Retardation:
Yes
No
Seizures:
Yes
No
Hyperkinesis:
Yes
No
Flacid Paralysis:
Yes
No
Other problems associated with DPT
Vaccine:
Additional Information
Do you currently have an attorney who represents you on your
claim?
Yes
No
