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Vaccine Injury Compensation Inquiry Form

Please fill out the following information and press the SUBMIT button. All fields must be completed. If you don't know the answer, simply write Don't Know. This form is for an informational request only and does not establish an attorney-client relationship. No attorney-client relationship can be created with this Firm absent the execution of a retainer agreement signed by both you and an authorized representative of the Firm.

Your Name:
Street Address:
City: , State: Zip Code:
Phone Number:
E-mail Address:

Name of individual suffering the adverse reaction:
Date of birth of individual suffering the adverse reaction:
Date of vaccinations:
Types of vaccines administered - please put all:
The date the initial symptoms of the adverse reaction occurred:

Date of first medical visit concerning the initial symptoms:
Please describe the adverse reaction experienced:

Please describe the health at present of the individual suffering the adverse reaction:

The above information will most likely need to be reviewed by multiple staff and attorneys at our Firm. On average we should be able to respond to your inquiry within one week. If more than one week has passed, please call us toll-free at 877-952-5242 for an update on our review.

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telephone toll free 877.952.5242 -- fax 941.952.5042
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