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Additionally, please ensure the "countermeasure" administered was within one year of the date this form is completed.

IMPORTANT: In order to receive a response, you must provide all information requested.

New Client Intake Form

* a "countermeasure" is not limited to vaccines. It also includes things like Remdesivir, ventilators, failure to administer Ivermectin, and other products/treatments administered (or failed to be administered) to COVID-19 patients 

THIS IS NOT A CLASS ACTION rather, if you were injured or a family member died as a result of COVID-19 related treatment (i.e., vaccine, ventilator, Remdesivir, etc.) in 2022 you may have a case that can be filed in federal court.

However, in order to do so, you must first, timely file a claim with the Countermeasures Injury Compensation Program ("CICP") within one (1) year of the date the injury/fatal causing countermeasure was administered.


In order for us to represent you, each client will be required to sign their own individual engagement agreement setting forth the costs, expenses, and scope of representation.


Which of the following caused the injury/death? (select all that apply)
Is the date selected within the last year?

Thank you, we'll review and get back to you shortly.


2300 Wilson Blvd. Ste 700

Arlington, VA 22201


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