[VLN-NEC] Reliable - Robin Law - Pulaski Intake Questionnaire

What is your legal first name? *

What is your legal middle name?

What is your legal last name? *

What is your relationship to the child? *

Did you have a different name at the time of the child's birth? *

If yes, what was that name?

What is your cell phone number? *

What is your email address? *

Do you have legal authority to sign on the injured party's behalf? *

What is your Current Street Number and Name? *

What is your city? *

What is your state? *

What is your zip code? *

If not the mother, please provide the mother's full name or any other aliases

Injured Child's Information

What is the child's legal first name? *

What is the child's legal middle name?

What is the child's legal last name? *

Has the child gone by any other name(s)? (Example: Baby Girl Last, Twin B, ect.) *

If yes, what was that name? (Child)

What is their date of birth? *

Did [Child's Name] pass away? *

IF DECEASED: What was their date of death?

IF DECEASED: Does the death certificate state the cause of death as NEC?

What is their gender? *

NEC & Hospital Information

What was your child's gestational age at birth? *

What was your child's weight at birth? *

How long was your child in the hospital for after birth? *

What type of milk did the child receive? *

What brand of formula was provided to the child?

Was your child diagnosed with NEC? *

For about how many days did your child take formula before NEC developed? *

Date of diagnosis:

What is the name of the hospital or facility where your child was born? *

Birth Hospital Street Number and Name *

Birth Hospital City *

Birth Hospital State *

Birth Hospital Zip Code *

Was your child transferred to a different hospital? *

If yes, what is the name of that hospital?

Transferred Hospital Address

Transferred Hospital City

Transferred Hospital State

Transferred Hospital Zip Code

What injuries did your child suffer as a result of the NEC diagnosis? *

Medical History surrounding birth and NEC stay. *

Other Hard Qualifiers

Are you currently represented by a law firm? *

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