GA Vaccine Injury Lawyer Form

1
Is your vaccine injury related to the COVID-19 vaccine?* This field is required.
YESNO
2
Did you receive any other vaccines on the same day as your COVID-19 vaccine?* This field is required.
YESNO
3
At this time, COVID-19 vaccine injury claims are only being filed in the Countermeasures Injury Compensation Program (CICP). Historically, only a handful of claims have been successful in this program, therefore, this firm is not handling claims in the CICP.

If and when the COVID-19 vaccine is added to the National Vaccine Injury Compensation Program (VICP), we will be happy to provide a free consultation and assessment of your potential claim, if any, in that program.

Visit our COVID-19 page and fill out our intake form for us to reach out to you should the situation change.
4
On the next page, please select the other vaccine you received on the same day as your COVID-19 vaccine.
5
Which vaccine caused your injury?* This field is required.
Flu
TdaP
Pneumococcal
DTaP
Meningococcal
MMR
Varicella
Hepatitis B
Hepatitis A
Hib
HPV
Polio
Rotavirus
6
What is the approximate date you received the vaccine(s)?* This field is required.
Date
Month
Day
Year
7
Todays Date
Date
Month
Day
Year
8
calculation widget
9
At this time, we are unable to work with vaccine injuries if vaccination occurred more than three years ago.
10
Did you receive an injury diagnosis from a doctor?* This field is required.
YESNO
11
Please describe your injury:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
What is your name?* This field is required.
First Name
Last Name
13
What is your phone number?* This field is required.
Please enter a valid phone number.
14
What is your email address?* This field is required.
example@example.com
15
Are you a U.S. citizen?* This field is required.
YESNO
16
Please verify that you are human* This field is required.
Should be Empty: