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Name(Required)

First Last

Email(Required)

Phone

Areas of Practice(Required)

Is This About a COVID-19 Vaccine Injury?(Required)

Approximate 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?

What was your diagnosis?

Name/Brand of Hip Implant:(Required)

Year 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?

Did You Have Revision Surgery or Are You Scheduled for Revision Surgery?(Required)

Date of revision surgery or upcoming 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?

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?

When 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)

What 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

Max. file size: 50 MB.

Upload any medical records or documents showing your diagnosis or injury from taking the medication.

Drop files here or

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?

Did you experience a permanent injury from eating the contaminated meat?

What 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?

What 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.

Comments

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As an experienced leader in these types of lawsuits, we were confident the firm would have the expertise. However, what surprised us most was the high level of excellent customer service from the firm’s staff!
Pat R.

I can’t recommend this firm enough. They have an outstanding team that truly care for their clients…I have been awarded a fair six figure settlement.
Nate M.

When I say “they went to bat” for me…this Law Firm literally did just that. They persevered to bring the hard-nosed Manufacturer to settle and provide me some recompense for everything I had to endure which led to this suit.
Me’Chelle

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