Name

Email Address

Phone Number

Did your child suffer a birth defect (or injury)?
Yes  No 

If not, are you related to the child?
Yes  No 

How?

When and where did you become aware of the birth defect (or injury)?

Was the child's mother taking any prescription or over-the-counter medication during pregnancy?
Yes  No 

Did the child's mother or the child experience any medical difficulties during childbirth?
Yes  No 

Do you know the names of any physicians, nurses, or other professionals who treated the mother during pregnancy and childbirth?
Yes  No 

What specific injuries were sustained as a result of the birth defect (or injury)?

What specific development, or physical and mental abilities have been affected by the birth defect (or injury)?

Is the child currently receiving medical treatment or rehabilitation as a result of the birth defect (or injury)?
Yes  No 

Have you discussed the child's birth defect (or injury) with any insurance representative or attorney representing other parties involved in the matter?
Yes  No 

How has the birth defect (or injury) affected your child's overall life experience and well-being? And yours?

DISCLAIMER: This site and any information contained herein is intended for informational purposes only and should not be construed as legal advice. Seek competent legal counsel for advice on any legal matter.