Intake Questionnaire
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Baby Food / Tylenol Intake Questionnaire

Please complete the short survey below regarding your claim. If you have any questions, please contact us at 888-480-1123.

Questionnaire

Is your child currently 15 years old or older?(Required)
Was your child born premature (less than 37 weeks gestation) and weighed under 5.5lbs at birth?(Required)
Did the mother suffer from diabetes during pregnancy?(Required)
Did the mother smoke or use any form of illicit drugs during pregnancy?(Required)

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(888) 480-1123
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