Free Case Review

Cerebral Palsy Information

This free case review form is very long and detailed. Do not feel it is required to fill out all fields and provide answers to every question. Do the best that you can. The more information we receive, the easier it is for our qualified attorneys to determine whether or not you may have a viable case.


	Contact Information

Fill out the following form or call 24 hours a day, 7 days a week for a Free Case Review.

First Name*
Last Name
	only one phone number is required
Home Phone*	- -
Work Phone*	- -
Cell Phone*	- -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip


	Injured Person's Contact Information

The injured person is
First Name:
Last Name:
Home Phone:	- -
Work Phone:	- -
Cell Phone:	- -
Email Address:
Street Address:
City:
State/City
Date of Birth
Sex	Male Female


Has your child been diagnosed with a birth injury?
Yes No Not sure

What has your child been diagnoses with?


When was your child diagnosed with condition/injury?


How old was your child when diagnosed?


Name of treating doctor.


Did the docotors report or state your child suffered from HIE (Hypoxic Ischemic Encephalophy)?
Yes No

Do you know the APGAR scores of your child at birth?
Yes No

Any lab readings made in delivery room?
Yes No

If yes, please answer the following:
Did the child have a seizure when born?
Yes No

If yes, were any anti-seizure medications adminsitered?
Yes No

Was child "blue" or discolored when born?
Yes No

Was child diagnosed with lacking oxygen?
Yes No

Was child sent to PICU (Pediatric Intensive Care Unit)?
Yes No

Any bleeding in the babys brain?
Yes No

Any blood samples taken imediatiely after birth?
Yes No

Any internal/external readings from fetal heart monitor?
Yes No

Any discussions with doctors as to a c-section prior to or during birth?
Yes - Prior Yes - During Yes - Both No

Were you aware or notified of any pregnancy red flags?
Yes No

If yes, did you suffer from any of the following?


Birth weight? (Select closest weight in pounds)


Any ultrasounds made?
Yes No

How many ultrasounds/birth scans made?


Any genetic testing for birth defects performed?
Yes No

If yes, what were the results of the tests?


Birthing History:
How many pregnancies and/or births by the mother?


Any previous complications in previous births?
Yes No

Was the pregnancy-monitoring doctor and the delivery doctor one in the same, or were they part of different medical groups?
Same Different medical groups

Name of Pregnancy doctor or medical group?


Name of Hospital, Birthing Center, or Clinic where child was born?


Any benefits received by the client for injuries from private insurance, Medicaid, Medi-Cal, Social Security, etc.?
Yes No

If yes, what benefits were provied and how much?


Have you talked to doctors, physicians, or lawyers about the injury?
Yes No

Any video recording of the birthing made?
Yes No

Please use this space to tell us any additional information you would like to provide

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	b. I agree that submitting this form and the information contained within does not establish an attorney client relationship..
	b. I agree that my information will be reviewed by more than one attorney and/or law firm.
	d. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.