Contact Us for Vaccine Injury Compensation 30021 Tomas Street, Suite 300 Rancho Santa Margarita, CA 92688 (949) 622-5572 [email protected] Name(Required)Email(Required) Phone Number(Required)MessageNameThis field is for validation purposes and should be left unchanged. Fill in the Details General Contact Information:Name(Required) First Name Middle Initial Last Name Address Street Address City State / Province / Region ZIP / Postal Code Name of Injured PartyDate of Birth of Injured Party MM slash DD slash YYYY What method would you prefer we use to contact you? Telephone E-Mail TelephoneEmail Address What time of day would you like us to call? Mornings Afternoons Evenings Vaccine Injury InformationType of VaccineOn what date was the vaccine taken? MM slash DD slash YYYY In what city and state did the vaccine reaction occur?On what date was the first sign or symptom of the vaccine reaction?Please explain in detail the reaction to the vaccine. (Use as many sheets as necessary to explain.)Please explain in detail the injured party’s current medical status. (Use as many sheets as necessary to explain.)Please explain in detail how the injured party was prior to the vaccine ( i.e. healthy, meeting all milestones, happy, cuddly, etc.)Are there any other questions you wish answered?"Please be advised that filling out this inquiry sheet does not constitute the Firm's agreement to represent you or your agreement to retain us. It is merely information gathering to determine if this is the type of case that qualifies for this Firm's representation. Nor, does it constitute legal advise. We will try to get back to you within a week of your e-mailing back to us "all" information requested. Incomplete responses or failure to respond to any of the questions will delay our ability to or prevent us from making a determination about the case. In many cases, delay beyond the three (3) years from the first onset of symptoms will prevent you from recovering damages from the National Vaccine Act Program."EmailThis field is for validation purposes and should be left unchanged.
