If you believe that you or someone close to you may have a vaccine injury claim, please fill out the following questionnaire. By submitting the information below, you will enable the attorneys at Conway, Homer & Chin-Caplan, P.C. to evaluate your case based on its merits. Please be as complete as possible in the information you provide.
Contact Information
Name of Injured Party:
Date of Birth of Injured Party:
E-mail:
Phone Number:
Work Phone:
Fax:
What method would you prefer we use to contact you?
What time of day would you like us to call?
Vaccine Information
Type of vaccine you believe caused this injury:
On what date was the vaccine (MM/DD/YY)?
/ /
On what date was the first sign or symptom of the vaccine reaction (MM/DD/YY)?
/ /
In what city and state did the vaccine reaction occur?
Please briefly explain the reaction to the vaccine: (Cannot be Blank)
Please briefly describe the vaccinee's current medical status: (Cannot be Blank)
Are there any other questions you wish answered? (Cannot be Blank)
The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship.
Attention Potential Autism Clients
On December 31, 2005, Conway, Homer & Chin-Caplan, P.C. has stopped accepting new cases alleging vaccines caused symptoms on the autism spectrum. Please be asssured we will continue to provide instructions (and forms) to persons who wish to file by themselves. However, those persons who still wish to file should be aware that:
1.
The deadline to file a claim in the Vaccine Program is, at the latest, three (3) years from the date of the diagnosis and possibly as early as three (3) years from the onset of symptoms;
2.
the presence of thimerosal (ethylmercury) in the Hep B, HiB, and/or DTaP vaccines is essential to our theory that these vaccines caused symptoms on the spectrum;
3.
manufacturers of these vaccines claim to have stopped using thimerosal in the production of new vaccines beginning in the year 2000; and
4.
there is a $250 filing fee required by the United States Court of Federal Claims.
Contact Information
Conway, Homer & Chin-Caplan
16 Shawmut Street
Boston, MA 02116
Phone: 617-695-1990
Fax: 617-695-0880
