Name
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First Name
Last Name
Email
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Phone Number
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Areas of Practice
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Please Select
Vaccine Injury
Metal on Metal Hip Replacements
Ozempic, Trulicity, Mounjaro, Wegovy, Rybelsus, Zepbound
Depo-Provera
Kratom Lawsuits
Food Recall
Indian Law
Federal Takings/Eviction Moratorium
Rails to Trails
Other
Choose a legal area that best fits your needs
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Is This About a COVID-19 Vaccine Injury?
*
Please Select..
YES
NO
Did you get any of these vaccinations in the 45 days before or after the COVID-19 shot? Flu, Tetanus, Pneumonia, Measles, Mumps, Rubella, MMR, Chickenpox/Varicella, Diptheria, Pertussis, DtaP, Rotavirus, Hepatitis A or B, Meningitis, HPV.
Please Select
Yes
No
Name of the vaccine or vaccines you got
*
Flu / Influenza
Tetanus
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
What year did you get the Non-COVID vaccination(s)?
Before 2022
2022
2023
2024
2025
Have you seen a doctor or medical professional for treatment?
*
Please Select..
YES
NO
What was your diagnosis?
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 was the original hip replacement surgery?
Before 2015
After 2015
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?
OPMS
Whole Herbs
Remarkable Herbs
MIT 45
Hush Kratom
KratoMade
Dr. Kratom
7-OHMZ
Pure Ohms
Zohm
7Tabz
Opia Hydroxy
CBD American Shaman
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 experience a severe injury related to a food recall?
Please Select..
YES
NO
What kind of medical treatment did you undergo?
Do you have receipts or the packaging from the recalled food product?
Please Select..
YES
NO
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 injection
2 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.
In what state do you currently live?
Tell us if there are additional details about your situation we should know about.
Please add additional information about what happened.
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