Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Areas of Practice
*
Please Select
Vaccine Injury
Metal on Metal Hip Replacements
Depo-Provera
Kratom or 7-OH Lawsuits
Cartiva Toe Implant
Dupixent
Olympus Endoscope
Ozempic, Trulicity, Mounjaro, Wegovy, Rybelsus, Zepbound
Federal Takings/Eviction Moratorium
Rails to Trails
Indian Law
Other
Choose a legal area that best fits your needs
case_type
Please Select
Vaccine Injury
Metal on Metal Hip Replacements
Depo-Provera
Kratom or 7-OH Lawsuits
Cartiva Toe Implant
Dupixent
Olympus Endoscope
Ozempic, Trulicity, Mounjaro, Wegovy, Rybelsus, Zepbound
Federal Takings/Eviction Moratorium
Rails to Trails
Indian Law
Other
Back
Next
Is This About a COVID-19 Vaccine Injury?
*
Please Select..
YES
NO
Did you get the Flu and COVID vaccine shots at the same time?
*
Please Select..
YES
NO
Date of COVID vaccine that caused the reaction:
What year did you get the vaccination(s)?
Before 2023
2023
2024
2025
2026
Name of the vaccine or vaccines you got
*
Flu / Influenza
Tetanus
Flu and COVID shot at the same time
Pneumonia / Pneumococcal
Chickenpox / Varicella
MMR or MMRV (Measles, Mumps, Rubella)
DTaP (Diphtheria, Tetanus, and Pertussis)
HPV / Gardasil
Whooping Cough / Pertussis
Rotavirus
Hepatitis A or Hepatitis B
Meningitis / Meningococcal
Hib / Haemophilus Influenzae Type B
Polio
Other non-COVID vaccine
Have you seen a doctor or medical professional for treatment?
*
Please Select..
YES
NO
Diagnosis:
*
Please Select
Shoulder Injury
SIRVA
Brachial Neuritis
Parsonage Turner Syndrome
Adhesive Capsulitis
GBS – Guillan Barre Syndrome
Blood Clots / Embolism
Stroke
Blood Disorder
Thrombocytopenia or ITP
Bell's Palsy
ADEM
Anaphylaxis / Allergic Reaction
Aplastic Anemia
CIDP
Celulitis
Complex Regional Pain Syndrome
Death
Encephalopathy / Encephalitis
Fainting
Myocarditis
Polymyalgia Rheumatica (PMR)
Polyneuropathy
Pemphigus
Rash
Seizures
Transverse Myelitis
Tinnitis / Ringing in the Ears or Hearing Loss
Vasculitis
Heart Issues
No Diagnosis
Other
If Diagnosis is Other, please list:
Name/Brand of Hip Implant:
*
Please Select..
Biomet
Johnson & Johnson DePuy Pinnacle
DePuy ASR
Zimmer
Stryker
Wright Medical
Other
I Don’t Know
What year did you have the original hip replacement surgery?
Did your doctor talk to you about metallosis, pseudotumors, high metal levels in your blood, bone loss, osteolysis, or joint loosening?
Please Select..
YES
NO
Did You Have Revision Surgery or Are You Scheduled for Revision Surgery?
*
Please Select..
YES
NO
Date of revision surgery or upcoming revision surgery
What are the names of the kratom brands that were used?
American Shaman
CBD American Shaman
OPMS
Whole Herbs
Remarkable Herbs
MIT 45
Hush Kratom
KratoMade
Dr. Kratom
7-OHMZ
Pure Ohms
Zohm
7Tabz
Opia Hydroxy
Other brand not listed above
If Other, what was the name of the brand?
Is this about a kratom death?
Please Select..
YES
NO
If there is an autopsy report, what was the cause of death?
If there is a toxicology report, what substances are listed?
Are you a member of a tribe?
Please Select..
YES
NO
Is your question about a tribal matter?
Please Select..
YES
NO
What is the name of the tribe:
What is the tribe's location?
Did you take any of the following medications?
Ozempic
Wegovy
Mounjaro
Trulicity
Rybelsus
Zepbound
Other
Was your medication the name brand or generic/compounded?
Name Brand
Generic/Compounded
I don't know
What state or states did you live in when taking the medication?
Which form of medication did you use?
Pre-loaded injection pen
Vial of medication with syringe injection
Pill form
Other
Are you still taking the medication now?
Please Select..
Yes
No
Have you been diagnosed by a doctor with any of these conditions: Gastroparesis, stomach paralysis, gastric stasis, delayed gastric emptying, intestinal blockage, bowel obstruction, ileal blockage?
*
Please Select..
Yes
No
Have you been diagnosed with any of these conditions? Check all that apply.
Pancreatitis
Deep Vein Thrombosis
Eye or vision stroke
Gallstones or gallbladder issues
Thyroid issues
Kidney issues
Stomach ulcers
Diabetes
Other
If Other, please describe:
Did you have non-rent paying tenants between Sept. 4, 2020 and October 2, 2021?
Please Select
YES
NO
Do you have a copy or can you get a copy of the tenant's Eviction Protection Declaration
Please Select
YES
NO
I DON'T KNOW
How many of your rental properties were impacted by the eviction moratorium?
Did you start taking Depo Provera AFTER 1992?
Please Select
YES
NO
About how many injections of Depo-Provera have you had?
Please Select
1-3 injections
4 or more injections
Have you been diagnosed with a meningioma tumor?
Please Select
Yes
No
What is your diagnosis after taking Depo-Provera?
Name of the clinic or medical provider where you got the prescription for Depo-provera.
What year was the Cartiva toe implanted?
What problems did you have with the implant?
Did you have revision surgery or are you scheduled for revision surgery to remove the Cartiva implant?
Please Select
Yes
No
How long did you use Dupixent?
Please Select
Less than 3 months
More than 3 months
Were you diagnosed with cancer or lymphoma after taking Dupixent?
Please Select
Yes
No
Did you have an endoscopy, colonoscopy, ERCP, or any other kind of scope procedure?
Please Select
Yes
No
When did the procedure take place?
Did you develop an infection within days or weeks of the procedure?
Please Select
Yes
No
What kind of medical care did you need because of the infection?
In what state do you currently live?
Tell us if there are additional details about your situation we should know about.
utm_source
utm_medium
utm_campaign
utm_content
utm_keyword
Submit
Should be Empty: