See If You Qualify Form

1

What best describes your situation?* This field is required.

I or a loved one developed a serious health condition after using a medication or medical product

I or a loved one developed a health condition after exposure to chemicals or environmental hazards

My child has developmental or health issues that may be linked to baby food or infant formula

I or a loved one experienced sexual abuse at an institution or by someone in a position of trust

I'm not sure / None of these apply

2

Which condition were you or your loved one diagnosed with?* This field is required.

Parkinson's Disease or movement disorder symptoms (tremors, stiffness, slow movement)

Brain tumor or Meningioma

Sickle cell crisis, severe hemolysis, or complications while on medication

Other condition not listed

3

What type of condition developed?* This field is required.

Parkinson's Disease or movement disorder (after herbicide/agricultural exposure)

Cancer (breast cancer, leukemia, lymphoma, or multiple myeloma)

Other condition not listed

4

What is your child experiencing?* This field is required.

Autism, developmental delays, or cognitive impairment

ADHD, speech delays, or learning disabilities

NEC (Necrotizing Enterocolitis) — typically in premature infants

Other health issues

5

We're here to help. Where did the harm occur?* This field is required.Note: You're not alone, and you don't need to share details right now. These questions just help us understand how to best support you.

A church or religious organization

A prison, jail, or detention facility

A school (K-12)

A college or university

A sports program or facility (gymnastics, dance, skating, swimming, etc.)

A youth organization (scouts, summer camp, etc.)

A healthcare or therapy setting

Another organization or institution

It wasn't connected to an institution

6

We'd still like to help. Which best describes your concern?* This field is required.

I have a health condition I believe was caused by a product or medication

I or my child was harmed by a medical device

I experienced harm or abuse

Something else

7

Were you exposed to Paraquat herbicide?* This field is required.

Yes, through my work (agricultural, commercial farm, mixing/applying chemicals)

I'm not sure if I was exposed

No, I don't believe I was exposed to herbicides

8

Did you use Depo-Provera (the birth control injection)?* This field is required.The generic name for this is Medroxyprogesterone Acetate (MPA).

Yes, for 1 year or longer

Yes, but for less than 1 year

I'm not sure which birth control I used

No, I never used Depo-Provera

9

Was the patient taking Oxbryta when the complications occurred?* This field is required.The generic name for this is Voxelotor.

Yes, actively taking Oxbryta

Yes, but had recently stopped taking it

I'm not sure which medication was being taken

No, Oxbryta was never prescribed

10

Were you exposed to Ethylene Oxide (EtO)?* This field is required.A flammable colorless gas with a sweet odor (at toxic levels). This is produced in large volumes and is used to manufacture products such as antifreeze, textiles, detergents, and plastics. It is also used to sterilize medical equipment.

Yes, I worked at or near a sterilization facility or medical device plant

Yes, I lived within 5 miles of an EtO-emitting facility

I'm not sure — I'd like help determining if there was a facility near me

No, I don't believe I was exposed

11

Did your child regularly consume store-bought baby food?* This field is required.

Yes, regularly (Gerber, Beech-Nut, Happy Baby, Earth's Best, etc.)

Yes, occasionally (mixed with homemade)

I'm not sure which brands or how often

No, only homemade baby food

12

Was your premature baby fed cow's milk-based formula?* This field is required.

Yes — Similac, Enfamil, or similar formula

Yes — a different or specialty formula

I'm not sure which formula was used

No — breast milk only

13

You don't need to share what happened — just let us know which organization so we can connect you with the right resources.* This field is required.

LDS / Mormon Church

Catholic Church

Another religious organization

I'd prefer not to specify

14

What type of facility were you in?* This field is required.This helps us identify the responsible parties. Your answers are confidential.

State prison

Federal prison

County jail

Juvenile detention facility

Private/for-profit prison

Immigration detention center

I'm not sure / Other

15

Was the person who harmed you in a role of authority or trust?* This field is required.For example: a teacher, coach, counselor, doctor, therapist, administrator, or staff member. This helps us understand who may be held accountable.

Yes

No, it was peer (another student, patient, participant, etc.)

I'm not sure/I'd rather not say

16

We're sorry for what you experienced. Was the person who harmed you in a position of trust in your life?* This field is required.For example: an employer, family friend, caregiver, landlord, or someone else you relied on. This can affect your legal options.

Yes

No

I'd rather not say right now

17

Please briefly describe your situation so we can better assist you.

18

You don't need to be exact — just a general sense of when this happened.* This field is required.You don't need to be exact — just a general sense of when this happened.

Within the last 2 years

2–10 years ago

10–20 years ago

More than 20 years ago

I was a minor when it happened

I'd prefer not to say

19

Phone Number* This field is required.

Please enter a valid phone number.

20

Name* This field is required.

First Name

Last Name

21

Please tell us the best time to call and your time zone.Examples: Mornings EST, Between 12 pm and 2 pm CST, Evenings PST

If you aren’t sure what time zone you are in, providing your zip code is also helpful but not mandatory.

22

Which state or are you in?* This field is required.This is important as it allows us to understand what the statute of limitations might be regarding your potential lawsuit.

23

Email

example@example.com

24

Anything else you want us to know?

25

Legal Disclosure* This field is required.By checking this box, I agree to the terms and consent to be contacted.

I understand that submitting this form does not create an attorney-client relationship. I also understand that The Legal Link - AZ LLC works with multiple law firms on these claims and that I may be contacted by an affiliated law firm working with The Legal Link - AZ LLC on these lawsuits.

26

Consent to Contact* This field is required.By checking this box, I agree to the terms and consent to be contacted.

I agree to receive communications via SMS, calls, and email from The Legal Link - AZ LLC or its associated vendors/organizations. Message and data rates may apply for SMS messages, and I may opt-out at any time by replying "STOP" to any SMS message received or by clicking the unsubscribe link in any email. I understand that this authorization overrides any previous registrations on a federal or state Do Not Call registry.

27

Please verify that you are human* This field is required.