[VLN-NEC] Reliable Marketing - Dugan Law Firm Intake Questionnaire

LEGAL

Have you been offered any form of compensation to call and talk to someone about a NEC claim? *

Have you been offered any form of compensation to answer a call and speak to someone about a NEC claim? *

Are you aware that being dishonest during this intake could be considered perjury which is a federal crime in the United States? *

Have you previously retained an attorney for a NEC claim? *

Is this claim for yourself or someone else? *

Caller Information

Full Name *

Full Address *

Email *

Phone *

Best Time to Reach Them *

Date of birth *

Social Security Number

Last 4 of SSN *

INJURED PARTY INFORMATION

Caller's Relationship to the Child *

Child's Full Name *

Child's Address *

Child's DOB *

Child's SSN

Child's Date of Death (If applicable)

Child Last 4 of SSN

PRODUCT USE

Formula Use Start Date *

Formula Use Stop Date *

How much time between formula use and injury? *

Formula Type Used *

Other Formula Type Used

DIAGNOSIS

Was the injured child born premature? *

How many weeks pregnant was mom when the child was born? (Must be 37 weeks or less) *

Child's Birth Weight (Must be 5lbs 8oz or less) *

Was child diagnosed with NEC? *

NEC Diagnosis Date *

Injury Caused by NEC *

Injury Notes *

What dates was the child in the NICU for? *

HEALTH CARE PROVIDERS

Diagnosing Doctor Name

Diagnosing Hospital Name *

Diagnosing Hospital Phone *

Diagnosing Hospital Address *

Treating Doctor Name

Treating Hospital Name *

Treating Hospital Phone (if different than Diagnosing Hospital)

Treating Hospital Address (if different than Diagnosing Hospital)

EMERGENCY CONTACT - Not Required But Highly Recommended

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Address

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