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:
Cell Phone:
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)?
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On what date was the first sign or symptom of the vaccine reaction (MM/DD/YY)?
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In what city and state did the vaccine reaction occur?
Please briefly explain the reaction to the vaccine, current medical status and questions you wished 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.
Contact Information
Conway, Homer & Chin-Caplan
16 Shawmut Street
Boston, MA 02116
Phone: 617-695-1990
Fax: 617-695-0880
