vaccine lawsuit: Free online consultation form

Has your child suffered adverse vaccine reactions? Get a free consultation at Monheit.com

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Do I have a vaccines case?

Do you qualify for a lawsuit from vaccine damages? Please complete our no obligation, free consultation form. Lawyers familiar with vaccines and vaccine experts are standing by to assist you.

PERSONAL INFORMATION

First Name:

Last Name:

Email:

Address:

City:

State:

Zipcode:

Phone: () - ext.

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, the person is deceased
No, the person is not deceased

If deceased, the cause of death as stated on the death certificate:

Date of Death:

Was there an autopsy performed?

Yes, an autopsy was performed
No, an autopsy was not performed

INJURY INFORMATION

Has person had any of the following injuries within 48 hours of recieving the vaccination:

Encephalopathy
Stroke
Heart Attack
Brain Injury
Death
Seizure
Gillian Barre Syndrome

DRUG INFORMATION

Has person had any of the following vaccinations:

Tetanus
Pertussis
Measles
Mumps
Chicken Pox (Varicella)
MMR
Rubella
Polio
Hepatitis B
Rotavirus (Rotashield)
Flu Shot
DTaP
DPT

Other:

Dates that Vaccine(s) were given?

Did behavior regress after receiving vaccines?

Yes, the behavior regressed
No, the behavior did not regress

If yes, please describe regressive behavior:

Other Information:

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