Infant Jaundice Injury Claim Intake
Please complete this form to submit your claim regarding an infant jaundice injury. All information will be used to evaluate your case.
Your Full Name
*
First Name
Last Name
Relationship to Infant
*
Parent
Guardian
Other
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Infant's Full Name
*
First Name
Last Name
Infant's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Injury or Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Hospital or Medical Facility
*
Name of Treating Medical Provider
Describe the injury, care received, and any lasting effects
*
Please upload any supporting documents (medical records, photos, etc.)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Claim
Submit Claim
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