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Yes

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Court Year*

Court Month*

Court Date*

Briefly Describe Your Case*

Do you already have an attorney?*

Yes

What was the cause of your injury?*

Injury Year*

Injury Month*

Injury Date*

What type of injury was sustained (if multiple, pick the main one)?*

Did you receive treatment within 14 days of the accident?*

Yes

Were you at fault for sustaining this injury?*

Yes

Briefly Describe Your Case*

Do you already have an attorney?*

Yes

How will you finance the legal representation?*

Briefly Describe Your Case*

Do you already have an attorney?*

Yes

How will you finance the legal representation?*

Marital status*

Briefly Describe Your Case*

Do you already have an attorney?*

Yes

When was the alleged crime committed?*

Have charges already been pressed?*

Yes

How will you finance the legal representation?*

Briefly Describe Your Case*

Do you already have an attorney?*

Yes

Have you already applied for social security / disability?*

Yes

Are you unable to work?*

Yes

Birth Year*

Birth Month*

Birth Date*

Do you receive social security benefits?*

Yes

Briefly Describe Your Case*

Do you already have an attorney?*

Yes

Birth Year*

Birth Month*

Birth Date*

Type of taxes owed?*

Total amount of taxes owed?*

Were you or a loved one diagnosed with any of the following Cancers after working on a Railroad for at least five years?*

Do you already have an attorney?*

Yes

Have you experienced any of the following symptoms after using Risperdal?*

Which one of the following medications did the injured male take?*

Do you already have an attorney?*

Yes

Briefly Describe Your Case*

Have you experienced any complications related to your IVC filter?*

Do you know which one of the following IVC Filter Brands caused you or a loved one injuries?*

Was the IVC Filter implanted after January 2003?*

Yes

Have you consulted with an Attorney on this case?*

Yes

Briefly Describe Your Case*

Have you experienced any complications related to your IVC filter?*

Did your side effect require you to be in the hospital for 24 hours or longer?*

Yes

Did any of those side effects due to Xarelto occur after January 2012?*

Yes

At the hospital, were you or a loved one directed to stop taking Xarelto by the Physician?*

Yes

Have you consulted with an Attorney on this case?*

Yes

Have you been diagnosed with Ovarian Cancer after using Talcum Powder?*

Yes

Did you or a loved one use Talcum Powder for 4 or more years?*

Yes

Are you or a loved one over the Age of 65?*

Yes

Did the loved one pass away from Ovarian Cancer within the last 3 years?*

Yes

Are you or a loved one BRCA Negative (Breast Cancer Susceptibility Gene)?*

Yes

Have you consulted with an Attorney on this case?*

Yes

Did you have a Bladder Sling or Transvaginal Mesh Surgery?*

Yes

Was this original Bladder Sling or Transvaginal Mesh Surgery performed in 2005 or after?*

Yes

What was the reason for your Bladder Sling or Transvaginal Mesh Surgery?*

Stress Urinary Incontinence (SUI)

Pelvic Organ Prolapse (POP)

Other (Please explain in comments)

Was the original surgery done Vaginally?*

Yes

Was there a Revision (replaced or removed) Surgery?*

Yes

Was the Revision Surgery performed in 2005 or later?*

Yes

Was the Revision Surgery performed Vaginally?*

Yes

Was the Revision Surgery performed while you were under Anesthesia?*

Yes

Have you consulted an Attorney in regards to this?*

Yes

Briefly Describe Your Case*

Have you consulted an Attorney in regards to this?*

Yes

Have you or a loved one experienced any of the following injuries or illnesses as a result of exposure to Camp Lejeune water contamination?*

Camp lejeune years, One of the following:*

Briefly Describe Your Case*

Type of relationship, One of the following:*

Have you consulted an Attorney in regards to this?*

Yes

Year of diagnosis, One of the following:*

Have you consulted an straightener use in regards to this?*

Yes

Have you experienced any of the following injuries or conditions after using Hair Relaxer?*

Have you been diagnosed with any of the following types of cancer after using Roundup?*

Type of exposure type, One of the following:*

Number of exposure year, One of the following:*

Have you consulted an Attorney in regards to this?*

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