Tylenol-Questionnaire

GET HELP AT NO COST: Fill out the form below to see if you are eligible to join. If you qualify, an attorney will contact you to discuss the details of your potential case at no charge to you.

Name *

First

Middle

Last

Phone

Email *

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Best time to contact you? Time7am-9am9am-12pm12pm-5pm5pm-7pm7pm-12am

Who are you filing out this form for?

Please select all diagnosis that apply *

• Autism Spectrum Disorder
• Asperger’s Syndrome
• Kanner’s Syndrome
• Pervasive Development DisorderC
• Hildhood Disintegrative Disorder (Heller’s Syndrome)

Approximate date of diagnosis

Were you over 45 years of age when you gave birth? *YesNo

Was your child born before the 26th week of pregnancy? *YesNo

Was one of the child’s parents diagnosed with autism? *YesNo

Is your child over 18 years of age? *YesNo

Any other details we should know?

Submit