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 to evaluate your case based on its merits. Please be as complete as possible in the information you provide.
General Contact Information:
First Name:

Last Name:

Street Address:

City:

State:

Zip:

Name of Injured Party:

Date of Birth of Injured Party:

 E-mail Address:

Phone Number:

Work Number:

Fax Number:
What method would you prefer we use to contact you?
What time of day would you like us to call?

General Information:
Type of vaccine?

On what date was the vaccine (00/00/00)? / /

On what date was the first sign or symptom of the vaccine reaction(00/00/00)? / /

In what city and state did the vaccine reaction occur?

Please briefly explain the reaction to the vaccine.

Please briefly describe the vaccinee's current medical status.
Additional Information:
Are there any other questions you wish answered?