SIRVA Questionnaire - You May Have a Vaccine Injury Case

We May be Able to Represent You in a SIRVA Case

Based on your SIRVA questionnaire responses, we may be able to represent you in a SIRVA case. We encourage you to contact us immediately because there is a deadline to file any vaccine injury compensation claim. Please complete the form below and someone from our vaccine injury team will get in touch with you.

Remember that in vaccine injury matters you have a very limited time in which to bring your claim. You need to give any attorney that you ask to review your case an adequate amount of time to complete their review and prepare to file the action. So do not delay.

Your case evaluation is free and there’s no cost or obligation to talk with our legal team.

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Name*

First Last

Email*

Phone

Areas of Practice*

Is This About a COVID-19 Vaccine Injury?*

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.*

Approximate month and/or year of vaccination:*

Name of Vaccine:*

Have you seen a doctor or medical professional for treatment?

What was your diagnosis?

Name/Brand of Hip Implant:*

Year of 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?

Did You Have Revision Surgery or Are You Scheduled for Revision Surgery?*

Date of revision surgery or upcoming revision surgery

Did you get a recall letter or notification?

Did You Have Revision Surgery or Are You Scheduled for Revision Surgery?*

Names of the kratom brands used

Type of Injury from Kratom

If there is an autopsy report, what was the cause of death?

If there is a toxicology report, what substances are listed?

Have you seen a medical provider about the kratom injury?

What is your medical diagnosis?

Are you still using kratom?

Have you gotten treatment for addiction or gone to rehab?

Are you a member of a tribe?

Is your question about a tribal matter?

What is the name of the tribe:

What is the tribe's location?

How long did you use the recalled Philips CPAP, BiPap or Ventilator?

Have you seen a doctor about an injury/reaction from the recalled device?

What is your diagnosis/injury after using the machine?

What is your injury if not listed above:

Please give us more details about your situation.

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