Thimerosal Case? Concerned about Thimerosal and Autsim?

Childhood-autism Lawsuits

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Protect your rights! Complete the Thimerosal Case Fight Back form, and talk to a Thimerosal case vaccine injury lawyer for free.

Now, you can have a trusted Thimerosal case vaccine injury lawyer in your corner — and your initial no-obligation vaccine injury consultation is free.

If your child has been vaccinated and suffers from autism, he or she may have suffered a vaccine injury from Thimerosal.

Don't delay any longer. Protect the rights of your child. Contact our Thimerosal case vaccine injury lawyers for a free inquiry.

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PERSONAL INFORMATION
Title*:
First Name*:
Last Name*:
E-mail Address*:
Address:

City:
State:
Zipcode:
Home Phone*:	() -
Work Phone:	() -
Mobile Phone:	() -
Injured Person Information
Date of Birth:

Whom are you inquiring on behalf of?
If you are NOT inquiring on your own behalf, what is your relationship?

Is their a medical diagnosis of autism or PDD NOS?	Yes No

If a diagnosis was of autism or PDD-NOS made,

when was the diagnosis of autism or PDD-NOS made?

who made the diagnosis of autism or PDD-NOS made?

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
Thimerosal
Child's date of birth:

Did mother receive Rhogam shot during pregnancy?
Yes No
Name of Vaccine(s) give that contained Thimerosal?

Dates that Vaccine(s) were given?

List name and address of Doctor's that gave Vaccine(s):

List name and address of hospital where Vaccine(s) was given:

Did child's behavior regress after receiving vaccines?	Yes No
If yes, please describe regressive behavior:

Did Autistic symptoms occur after vaccine(s) was given?
Yes No
When was first symptom of a vaccine injury?

Was a test for mercury performed?	Yes No
If yes, what were the results of mercury test:

Other Information related to Thimerosal and Autism or your child's vaccine injury claims:

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