See If We Can Help

See If We Can Help
This form is HIPAA-compliant. All details you provide in this form are handled in accordance with HIPAA privacy and security standards. Your responses are encrypted, securely transmitted, and used only for the purpose of evaluating your potential case.
Please complete the questions below to determine if we're the right resource for your needs. If your inquiry is related to the claim against Dr. Howard Saal and Cincinnati Children's Hospital, please click here to fill out that case-specific form.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Are you submitting this form for yourself or on behalf of someone else?*

MyselfSomeone else
Who are you reaching out on behalf of?
Does your situation involve a physical injury, a birth injury, or a death?*

NoYes
Does your situation involve any of the following? Select all that apply.*

Physical harm (an injury requiring medical care, like broken bones, brain damage, organ damage, concussion, etc.)A birth injury (NICU admission, birth trauma, seizures, brain damage, HIE, shoulder dystocia, brachial plexus injury)Abuse (child abuse, elder abuse, sexual abuse, daycare abuse, etc.)A deathNone of the above are applicable
Is the injured party a minor?*

NoYes
Where did the incident happen?*

OhioKentuckyAnother state
When did the incident happen?*

Within the past yearWithin the past 2 yearsMore than 2 years ago
Please indicate all circumstances that apply to the incident (can select more than one)*

The injured party was a minorWrongful deathThe injury was discovered recentlyNone of the above are applicable
Was an autopsy performed?

YesNoN/A
If the injury was physical (broken bones, brain damage, organ damage, etc.), is the injured party fully recovered?

YesNoDeceasedN/A
Can you please briefly describe the incident?
How did you hear about us?*

Personal NetworkGoogleSocial MediaRadioOther
If you heard about us through a referral, who referred you to us?
Were you referred to a specific attorney?
Please verify that you are human*
Current Date

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