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Toxic Baby Formula (NEC) Lawsuit Qualifier
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What is the relation the injured child?
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Parent
Court-ordered legal guardian
Myself
Relative
Friend
Healthcare Worker
Was the child born premature?
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Yes
No
Select the formula or milk fed to the child PRIOR to the diagnosis.
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Alimentum Formula Powder
EleCare Formula
Enfamil Formula
Enfamil Milk Fortifier
Similac Formula
Similac Milk Fortifier
Other brand of formula
Other brand of milk fortifier
Mother’s breastmilk
Donor's breastmilk
Select any of the following diagnosis that the child has received.
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Necrotizing Enterocolitis (NEC)
Short Bowel Syndrome*
Other gastrointestinal diagnosis or injury*
Has the child had surgeries as a result of the diagnosis or injury?
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Yes
No
Did the child stay in the NICU (newborn intensive care unit) for one week or longer?
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Yes
No
Select any additional injuries after the diagnosis.
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Intestinal Perforation (a hole in the intestines)
Scarring or strictures (narrow areas) in the intestines
Sepsis (severe infection affecting the entire body)
Cerebral palsy
Neurological damage
Abdominal pain and swelling
Changes in heart rate, breathing, blood pressure or body temperature
Lethargy
Diarrhea with bloody stool
Green or yellow vomit
Refusing to eat
Lack of weight gain
Other injury
No Injuries
Child's Approximate Date of Birth?
*
What state was the child born in?
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AL ALABAMA
AK ALASKA
AZ ARIZONA
AR ARKANSAS
CA CALIFORNIA
CO COLORADO
CT CONNECTICUT
DE DELAWARE
FL FLORIDA
GA GEORGIA
HI HAWAII
ID IDAHO
IL ILLINOIS
IN INDIANA
IA IOWA
KS KANSAS
KY KENTUCKY
LA LOUISIANA
ME MAINE
MD MARYLAND
MA MASSACHUSETTS
MI MICHIGAN
MN MINNESOTA
MN MINNESOTA
MO MISSOURI
MT MONTANA
NE NEBRASKA
NV NEVADA
NH NEW HAMPSHIRE
NJ NEW JERSEY
NM NEW MEXICO
NY NEW YORK
NC NORTH CAROLIINA
ND NORTH DAKOTA
OH OHIO
OK OKLAHOMA
OR OREGON
PA PENNSYLVANIA
PR PUERTO RICO
RI RHODE ISLAND
SC SOUTH CAROLINA
SD SOUTH DAKOTA
TN TENNESSEE
TX TEXAS
UT UTAH
VT VERMONT
VA VIRGINIA
WA WASHINGTON
DC WASHINGTON D.C.
WV WEST VIRGINIA
WI WISCONSIN
WY WYOMING
Are you working with another law firm regarding these injuries?
*
Yes
No
Would you like to speak to a lawyer regarding your potential claim? (Consultations are always free)
Yes
No
Name
*
First
Last
Email
*
Phone Number
*
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