Please take a minute or two to fill out the form below. All information submitted are fully confidential. Please see our Privacy Policy. We will respond to you as soon as possible.

The following contact fields are all required unless indicated as "optional":

Your name:
Your child's name (optional):
Child's date of birth:	monthJanuary February March April May June July August September October November December day1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year1998 1999 2000 2001 2002 2003 2004 2005
State your child was born in :	Select a State ------------------------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
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Alternative phone with area code (optional):
Your email address:
Your home address:

 

To help us understand your case better, please answer all the questions if possible. If a particular answer is unknown or not applicable to your situation, choose "Not Sure".

Is your child diagnosed of cerebral palsy, any form of brain damage or Erb's palsy?
Yes No Not Sure
How long did the mother carry?
More than 40 weeks 37-40 weeks 32-36 weeks Less than 32 weeks
Was mother's labor induced?
Yes No Not Sure
What is the method of delivery?
Natural birth Planned C-section Emergency C-section
Did the doctor use forceps or vacuum extraction during delivery?
Yes, used forceps Yes, used vacuum extraction No Not Sure
Was the delivery difficult?
Yes No Not Sure
If the answer to above question is "Yes", please describe:
Was the delivery delayed?
Yes No Not Sure
Was the mother connected to an electronic fetal monitor during labor?
Yes No Not Sure
Was any form of annesthetics used during labor?
Yes, Epidural Yes, general annesthesia Yes, other types or not sure what type No
Was there meconium (baby's first feces, ordinarily passed after birth) in the amniotic fluid?
Yes No Not Sure
Did the child 's heart rate drop prior to birth?
Yes No Not Sure
Was the child breathing on his/her own after birth?
Yes Yes but not normally No Not Sure
What was the child's skin color at birth?
Normal Blue Pale
Was the child moving at birth?
Yes Yes but not normally No Not Sure
Did the child require resuscitation or CPR?
Yes No Not Sure
Did the child have seizures, shakes, tremors within 48 hours after delivery?
Yes No Not Sure
Was the child in the Neonatal Intensive care Unit?
Yes No Not Sure
If the answer to above question is "Yes", please specify how long:
Did the mother have diabetes during this pregnancy?
Yes No Not Sure
Did the mother have high blood pressure during this pregnancy?
Yes No Not Sure
Did the mother have fever during labor?
Yes No Not Sure
Was the pregnancy high risk?
Yes No Not Sure
Did your child have a MRI, Ultrasound, or CT scan of the brain?
Yes No Not Sure
What is the child's birth weight?
Hospital or birthing center your child is born at:
How did the child appear immediately after birth?
Please enter additional information regarding the birth process, child's condition and what you think went wrong:
Please describe your child's injury or condition NOW: