First Name

Last Name

May I have your email address? *

May I have a good phone number for you in case we get disconnected? *

Date of birth *

Do you have an alternative phone?

Do you have an attorney representing you for this matter?

(If Yes, Disqualify)

Did you receive intramuscular injections of Depo-Provera as a form of birth control?

Yes

No

(If No, Disqualify)

Where were you living when you received the injections? *

Provide address

During what time period did you receive the injections? (If less than one year, Disqualify) *

(If less than one year, Disqualify) Use the full date in written form (e.g., December 1, 2020) when possible.

How many injections did you receive?

When was your first injection? *

When possible, provide the full date in written form (ie. December 20, 2022)

When was your last injection? *

Use the full date in written form (e.g., December 1, 2020) when possible.

Who prescribed Depo-Provera to you? *

Physician’s Name
Physician’s Specialty

Before you received your injections, were you informed of a connection between Depo-Provera and the development of brain tumors?

To your knowledge, did you receive the brand name Depo-Provera or a generic version? *

If you believe you received a generic version, what was the name?

To your knowledge, did you receive injections of Depo-SubQ Provera 104, a lower dose version of Depo-Provera?

Have you been diagnosed with meningioma, a tumor in the meninges surrounding the brain? (If No, Disqualified)

Yes

No

(If No, Disqualified)

When were you diagnosed? *

Use the full date in written form (e.g., December 1, 2020) when possible.

How were you diagnosed? For example, did your physician order an MRI that revealed the tumor? *

If "Other," please specify the location of the tumor. *

To your knowledge, was it in the sphenoid-orbital region? In other words, was it located near your eyes and/or sinuses? *

Have you undergone surgery to remove the meningioma? *

What type of surgery was it?

Where was the surgery performed? *

Who performed the surgery? *

To your knowledge, were there any complications during the surgery? *

Since the surgery, which of your symptoms, if any, have resolved or improved? *

Other than the meningioma attributed to your Depo-Provera use, have you ever been diagnosed with any other brain tumors?

Yes

No

(If Yes, Disqualify)

Have you ever been diagnosed with pseudotumor cerebri or intracranial hypertension?

Yes

No

(If Yes, Disqualify)

Have you ever been diagnosed with acoustic neuroma, vestibular schwannoma, or pituitary adenoma?

Yes

No

(If Yes, Disqualify)

Have you ever been diagnosed with uterine or endometrial cancer?

Yes

No

(If Yes, Disqualify)

Have you ever been diagnosed with osteoporosis or low bone marrow density?

Yes

No

Last 4 SSN

Do you have access to MyChart?

Yes

No

Mychart is a personal health record portal.

Driver's License Number

What is the best time for the law firm to reach you?

Deprovera - Intake Form