mctlaw Privacy Policy Contact Us Now Contact Us Now Step 1 of 2 50% Name(Required) First Last Email(Required) PhoneAreas of Practice(Required)Please Select…Vaccine InjuryMetal on Metal Hip ReplacementsOzempic, Trulicity, Mounjaro, Wegovy, Rybelsus, ZepboundDepo-ProveraKratom LawsuitsBoars Head Listeria OutbreakIndian LawFederal Takings/Eviction MoratoriumRails to TrailsOther Is This About a COVID-19 Vaccine Injury?(Required)Please Select..YESNOApproximate month and/or year of vaccination:(Required) Name of the vaccine or vaccines you got:(Required) Flu / Influenza Tetanus Pneumonia / Pneumococcal Chickenpox / Varicella Measles, Mumps, Rubella (MMR or MMRV) HPV / Gardasil Whooping Cough / Pertussis Rotavirus Hepatitis A or Hepatitis B Meningitis / Meningococcal DTaP (Diptheria, Tetanus, and Pertussis) Hib / Haemophilus Influenzae type b Polio Other non-COVID vaccine Have you seen a doctor or medical professional for treatment?Please Select..YESNOWhat was your diagnosis? Name/Brand of Hip Implant:(Required)Please Select..BiometJohnson & Johnson DePuy PinnacleDePuy ASRZimmerStrykerWright MedicalOtherI Don’t KnowYear of Original Hip Replacement Surgery:(Required) Did your doctor talk to you about metallosis, pseudotumors, high metal levels in your blood, bone loss, osteolysis, or joint loosening?Please Select..YESNODid You Have Revision Surgery or Are You Scheduled for Revision Surgery?(Required)Please Select..YESNODate of revision surgery or upcoming revision surgery Names of the Kratom brands used Type of Injury from KratomPlease Select..Death of Family Member or FriendMedical Reaction Like Seizures, Heart Problems, Organ Failure, Etc.Addiction For Which You Are Getting TreatmentOtherIf 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?Please Select…YESNOWhat is your medical diagnosis? Are you still using kratom?Please Select…YESNOHave you gotten treatment for addiction or gone to rehab?Please Select…YESNOAre you a member of a tribe?Please Select..YESNOIs your question about a tribal matter?Please Select..YESNOWhat 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 is the name of the pharmacy or website where you ordered the prescription? Which form of medication did you use? Pre-loaded injection pen Vial of medication with syringe injection Pill form Other When did you start taking the GLP-1 medication? (month and year) Have you stopped taking it?Please Select..YesNoWhen did you stop taking the medication? (Month and year) Have you been diagnosed with a medical condition by a doctor after taking the medication?(Required)Please Select..YesNoWhat is the diagnosis or condition:(Required) What kind of medical care did you undergo for new or worsening symptoms AFTER you started taking the medicine? Check all that apply. Surgery Hospitalized for one or more nights Urgent care or ER visit Treatment by primary care doctor or specialist Other No Medical Treatment Yet If other, describe the medical care you received:Do you have documentation to show you were prescribed and/or filled the prescription for the drug? Please check all that apply. Photo of medication packaging Paper prescription Pharmacy records Online medical records Medication packaging or box with prescription label Emails from medical provider or pharmacy Other None Upload images or other proof of prescription here. Drop files here or Select files Max. file size: 50 MB. Upload any medical records or documents showing your diagnosis or injury from taking the medication. Drop files here or Select files Max. file size: 50 MB. Tell us if there are additional details about your situation we should know about.Are you contacting us on behalf of a deceased family member/friend?Please Select..YESNODid you experience a permanent injury from eating the contaminated meat?Please Select..YESNOWhat kind of medical treatment did you undergo because of the listeria poisoning? Do you have receipts or the packaging from the recalled Boar's Head Deli meats?Please Select..YESNOWhat year did you first start getting Depo Provera shots? About how many injections of Depo-Provera have you had? What is your diagnosis after taking Depo-Provera?(Required) Name of the clinic or medical provider where you got the prescription for Depo-provera? Please add additional information about what has happened.I agree to the Terms and Conditions outlined in this link by submitting this information to mctlaw.CommentsThis field is for validation purposes and should be left unchanged. Step 1 of 2 50% Name(Required) First Last Email(Required) PhoneAreas of Practice(Required)Please Select...Vaccine InjuryMetal on Metal Hip ReplacementsOzempic, Trulicity, Mounjaro, Wegovy, Rybelsus, ZepboundDepo-ProveraKratom LawsuitsBoars Head Listeria OutbreakIndian LawFederal Takings/Eviction MoratoriumRails to TrailsOther Is This About a COVID-19 Vaccine Injury?(Required)Please Select..YESNOApproximate month and/or year of vaccination:(Required) Name of the vaccine or vaccines you got:(Required) Flu / Influenza Tetanus Pneumonia / Pneumococcal Chickenpox / Varicella Measles, Mumps, Rubella (MMR or MMRV) HPV / Gardasil Whooping Cough / Pertussis Rotavirus Hepatitis A or Hepatitis B Meningitis / Meningococcal DTaP (Diptheria, Tetanus, and Pertussis) Hib / Haemophilus Influenzae type b Polio Other non-COVID vaccine Have you seen a doctor or medical professional for treatment?Please Select..YESNOWhat was your diagnosis? Name/Brand of Hip Implant:(Required)Please Select..BiometJohnson & Johnson DePuy PinnacleDePuy ASRZimmerStrykerWright MedicalOtherI Don’t KnowYear of Original Hip Replacement Surgery:(Required) Did your doctor talk to you about metallosis, pseudotumors, high metal levels in your blood, bone loss, osteolysis, or joint loosening?Please Select..YESNODid You Have Revision Surgery or Are You Scheduled for Revision Surgery?(Required)Please Select..YESNODate of revision surgery or upcoming revision surgery Names of the Kratom brands used Type of Injury from KratomPlease Select..Death of Family Member or FriendMedical Reaction Like Seizures, Heart Problems, Organ Failure, Etc.Addiction For Which You Are Getting TreatmentOtherIf 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?Please Select...YESNOWhat is your medical diagnosis? Are you still using kratom?Please Select...YESNOHave you gotten treatment for addiction or gone to rehab?Please Select...YESNOAre you a member of a tribe?Please Select..YESNOIs your question about a tribal matter?Please Select..YESNOWhat 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 is the name of the pharmacy or website where you ordered the prescription? Which form of medication did you use? Pre-loaded injection pen Vial of medication with syringe injection Pill form Other When did you start taking the GLP-1 medication? (month and year) Have you stopped taking it?Please Select..YesNoWhen did you stop taking the medication? (Month and year) Have you been diagnosed with a medical condition by a doctor after taking the medication?(Required)Please Select..YesNoWhat is the diagnosis or condition:(Required) What kind of medical care did you undergo for new or worsening symptoms AFTER you started taking the medicine? Check all that apply. Surgery Hospitalized for one or more nights Urgent care or ER visit Treatment by primary care doctor or specialist Other No Medical Treatment Yet If other, describe the medical care you received:Do you have documentation to show you were prescribed and/or filled the prescription for the drug? Please check all that apply. Photo of medication packaging Paper prescription Pharmacy records Online medical records Medication packaging or box with prescription label Emails from medical provider or pharmacy Other None Upload images or other proof of prescription here. Drop files here or Select files Max. file size: 50 MB. Upload any medical records or documents showing your diagnosis or injury from taking the medication. Drop files here or Select files Max. file size: 50 MB. Tell us if there are additional details about your situation we should know about.Are you contacting us on behalf of a deceased family member/friend?Please Select..YESNODid you experience a permanent injury from eating the contaminated meat?Please Select..YESNOWhat kind of medical treatment did you undergo because of the listeria poisoning? Do you have receipts or the packaging from the recalled Boar's Head Deli meats?Please Select..YESNOWhat year did you first start getting Depo Provera shots? About how many injections of Depo-Provera have you had? What is your diagnosis after taking Depo-Provera?(Required) Name of the clinic or medical provider where you got the prescription for Depo-provera? Please add additional information about what has happened.I agree to the Terms and Conditions outlined in this link by submitting this information to mctlaw.NameThis field is for validation purposes and should be left unchanged.
