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    • Talcum Powder / Cancer Litigation
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    • Wrongful Death
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    • Mesothelioma
    • Silica and Silicosis
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NEC Intake Form

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THE SMITH LAW FIRM, PLCC - NEC Litigation Intake Form

This secure information form helps us get to know more about you, your infant's injury, and how The Smith Law Firm may be able to help you with your potential case. You may save this form in case you are interrupted by clicking the "Save" button to allow you to pick up where you left off.

Injured Party Information (Infant):

Please provide this info for the infant who was diagnosed with NEC.
Infant Name(Required)
Infant Address(Required)
Date of Birth(Required)
A Social Security Number is required by medical providers to ensure they release the correct, official medical records.
Date of Death (if applicable)
If your infant is deceased, please list the state in which your infant passed away
Gender(Required)

Personal Representative Information (Mother):

Mother's Legal Name(Required)
Mother's Address(Required)
Mother's Date of Birth(Required)
Social Security Numbers are required by medical providers to release official medical records.
Is The Smith Law Firm representing this parent?(Required)

Personal Representative Information (Father):

Father's Legal Name(Required)
Father's Address(Required)
Father's Date of Birth(Required)
Social Security Numbers are required by medical providers to release official medical records.
Is The Smith Law Firm representing this parent?(Required)

Secondary Contact Persons

We recommend that you add secondary contacts to help us get in touch if we lose contact with you and need to hear from you, or to continue your case if you become incapacitated.
Secondary Contact Legal Name(Required)
Address(Required)
Do we have permission to speak with this secondary contact about your representation by our firm?(Required)
Additional Secondary Contact Legal Name (if applicable)
Address
Do we have permission to speak with this secondary contact re your representation by our firm?

Infant Product Use

Which of the following products may have been consumed by your infant?
Was cow-milk based formula given to infant?(Required)
Was cow-milk fortifier given to infant?(Required)
Was infant given maternal breast milk?(Required)
Was infant given donor breast milk(Required)

Infant Diagnosis & Treatment Details

Was your infant diagnosed with NEC?(Required)
Address of facility where infant was born?(Required)
Address of facility where diagnosed with NEC, if different
Please indicate whether you are aware of the Infant having been diagnosed with any of the following conditions or procedures or receiving any of the following medications during the Infant’s hospitalization for his/her birth, or in the NICU (if transferred, whichever is later).
Prematurity(Required)
Low birth weight(Required)
Sepsis(Required)
Congenital heart disease(Required)
Assisted ventilation(Required)
Patent ductus arteriosus(Required)
Anemia(Required)
Administration of Indomethacin(Required)
Administration of Glucocorticoids(Required)
Gastroschisis(Required)
Red blood cell transfusion(Required)
Hypoxia(Required)
Hypotension(Required)
Hypoalbuminemia(Required)
Family history of necrotizing enterocolitis(Required)
Please indicate whether Mother’s medical history includes any of the following conditions, procedures, or medications during any pregnancy with the Infant.
Chorioamnionitis(Required)
Pre-eclampsia(Required)
In utero growth restriction(Required)
Placental abruption(Required)
Prenatal antibiotics(Required)
Prenatal corticosteroids(Required)
Intrahepatic cholestasis during pregnancy(Required)
Premature rupture of membranes (water breaking early)(Required)
Smoking(Required)
Cocaine use(Required)
Methamphetamine use(Required)
Amphetamine use(Required)
Alcohol use(Required)
HIV(Required)
Once you have completed entering your information, please click the SUBMIT button below.
Address
Now that you have completed this form, it will be securely submitted to The Smith Law Firm team to begin processing. Please click Submit to send us your intake form.
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PLLC 300 Concourse Blvd.
Suite 104
Ridgeland, MS 39157

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