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Name * Phone * Email Injury Type Injury TypeMotor Vehicle AccidentMedical MalpracticeBirth InjuryPedestrian AccidentDog BitesSlip & FallWrongful DeathOther
Type of Birth InjuryApgar ScoresBirth ParalysisBrachial Plexus PalsyBrain Damage/Head TraumaC Section CasesCephalohematomaCephalopelvic DisproportionCerebral PalsyClavicle FractureCortical BlindnessDelivery by Forceps or Vacuum ExtractionErb’s PalsyFacial ParalysisHydrocephalusHypoxic-Ischemic Encephalopathy (HIE)Infant Wrongful DeathKernicterusKlumpke’s PalsyMacrosomiaMeconium Aspiration SyndromNeonatal HypoxiaNeonatal Therapeutic HypothermiaPeriventricular LeukomalaciaPlacental AbruptionPreeclampsiaRetinopathy PrematurityShoulder DystociaTorticollis (Wry Neck)Uterine RuptureMore than one of the aboveOther What do you believe caused the birth injury?Unsure at this timeBreeched BirthCesarean Delivery (C-Section)Forceps UseLack of OxygenPlacental abruptionProlonged LaborVacuum DeliveryWrong Medicine or DosageOther Reason(s)
What type of medical malpractice?Surgical ErrorsDiagnostic Errors/Failure to DiagnoseEmergency Room ErrorsHospital InjuriesBirth InjuriesPrenatal InjuriesNegligent IntubationAnesthesia ErrorsPrescription ErrorsDefective Medicine or EquipmentPlastic Surgery MalpracticeWrongful PregnancyMore than one of the aboveOther
Type of treatment that was receivedHospitalizedEmergency room / Urgent careSaw doctor or specialistIntend to seek treatmentOther treatmentNo Injury Which parties involved in the accident have insurance?One partyAll partiesNo partiesI do not know
Who was injured by the dog?A family member was bitten & injured by a dogI was chased by a dog and suffered an injuryMore than one of the aboveOther What was the nature of the injury?Open Wounds and BleedingSkin/Tissue InfectionFractured limbInfective ArthritisSepsis / Blood PoisoningInjuries from Being ChasedOther Connective Tissue InjuryDeathNo injuryOther
State What state did the injury occur in?AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming
Injury DateMonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear2023202220212020201920182017201620152014
Tell us what happened *
Injury TypeMotor Vehicle AccidentMedical MalpracticeBirth InjuryPedestrian AccidentDog BitesSlip & FallWrongful DeathOther
Type of Birth InjuryApgar ScoresBirth ParalysisBrachial Plexus PalsyBrain Damage/Head TraumaC Section CasesCephalohematomaCephalopelvic DisproportionCerebral PalsyClavicle FractureCortical BlindnessDelivery by Forceps or Vacuum ExtractionErb’s PalsyFacial ParalysisHydrocephalusHypoxic-Ischemic Encephalopathy (HIE)Infant Wrongful DeathKernicterusKlumpke’s PalsyMacrosomiaMeconium Aspiration SyndromNeonatal HypoxiaNeonatal Therapeutic HypothermiaPeriventricular LeukomalaciaPlacental AbruptionPreeclampsiaRetinopathy PrematurityShoulder DystociaTorticollis (Wry Neck)Uterine RuptureMore than one of the aboveOther
What do you believe caused the birth injury?Unsure at this timeBreeched BirthCesarean Delivery (C-Section)Forceps UseLack of OxygenPlacental abruptionProlonged LaborVacuum DeliveryWrong Medicine or DosageOther Reason(s)
Type of treatment that was receivedHospitalizedEmergency room / Urgent careSaw doctor or specialistIntend to seek treatmentOther treatmentNo Injury
Which parties involved in the accident have insurance?One partyAll partiesNo partiesI do not know
Who was injured by the dog?A family member was bitten & injured by a dogI was chased by a dog and suffered an injuryMore than one of the aboveOther
What was the nature of the injury?Open Wounds and BleedingSkin/Tissue InfectionFractured limbInfective ArthritisSepsis / Blood PoisoningInjuries from Being ChasedOther Connective Tissue InjuryDeathNo injuryOther
What state did the injury occur in?AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming
Injury MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberInjury Year2023202220212020201920182017201620152014
