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A CASE FOR WOMEN – Baby Carrier Questions
Questions? Call us at
(888) 373-7888
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PERSONAL AND CONFIDENTIAL – PROSPECTIVE CLIENT COMMUNICATION
Hip Issues
Have you taken your child to the doctor to discuss hip problems?
*
Yes
No
When was the visit?
If you are unsure, an approximate date is fine.
Month diagnosed
*
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year diagnosed
*
Year:
-select-
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
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1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
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1968
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1933
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1931
1930
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1926
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1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Name of Doctor:
*
Name and address of facility:
*
Hidden
Has your child been diagnosed with any of the following?(removed)
Hip Dysplasia
Minor laxity of the hip(s)
Dislocation of the hip(s)
Developmental Dislocation of the Hip (DDH)
Avascular Necrosis
Arthritis of the Hip(s)
None of the Above
Has your child been diagnosed with any of the following?
*
Select
Hip Dysplasia
Minor laxity of the hip(s)
Dislocation of the hip(s)
Developmental Dislocation of the Hip (DDH)
Avascular Necrosis
Arthritis of the Hip(s)
None of the Above
Other
Other - please explain:
*
When were they diagnosed?
If you are unsure, an approximate date is fine.
Month diagnosed
*
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year diagnosed
*
Year:
-select-
2023
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Diagnosing Doctor:
*
Name and address of diagnosing facility:
*
Did you use a Pavlik Sling to resolve the injury?
*
Yes
No
Was it successful?
*
Yes
No
Did further treatment occur?
*
Yes
No
Did you use a Rhino Brace to resolve the injury?
*
Yes
No
Was it successful?
*
Yes
No
Did further treatment occur?
*
Yes
No
Please list any other info you would like us to know about your child’s diagnosis or condition:
Carrier Info
Did you use one of the following models of baby carriers?
*
Select
Baby Bjorn - Baby Carrier Original
Chicco - Ultrasoft Infant Carrier
Infantino - Swift Classic Carrier
Evenflo - Breathable Carrier
Evenflo - Easy Infant Carrier
Evenflo - Active Carrier
Evenflo - babyGo
Evenflo - Snugli Comfort
Mission Critical - S.01 Action Baby Carrier
Budu Baby Carrier
Britax Baby Carrier
Graco - Soft Infant Baby Carrier
Other
Other (please list manufacturer name if you know it):
Hidden
Did you buy the carrier new (not previously used)?
Yes
No
Was the carrier new at start of use?
*
Yes
No
Did you buy it from a secondhand retailer?
*
Yes
No
Usage Info
Approximately how often did you use the carrier?
*
Less than 20 times
20-50 times
50 or more times
Other
Other - please explain:
What approximate age range was your child when you used the carrier?
*
Birth and Diagnosis Info
Did your doctor say the diagnosis was caused by any of the following - Breech birth, Premature birth (32 weeks or earlier), Traumatic fall or dropping incident, Congenital hereditary hip issues?
*
Breech birth
Premature birth (32 weeks or earlier)
Traumatic fall or dropping incident
Congenital hereditary hip issues
None of the above
Did you have an emergency C-section?
*
Yes
No
Do you have an upcoming doctor’s appointment to discuss hip issues?
*
Yes
No
When is the appointment?
If you are unsure, an approximate date is fine.
Month diagnosed
*
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year diagnosed
*
Year:
-select-
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Name of Doctor:
*
Name and address of facility:
*
What age is your child now?
Hidden
Other Info
Please list any other info you would like us to know about your child’s birth:
Child’s Info
Please fill in this section with your child's information
Your Child's Legal Name:
First Name
*
Middle Name
Last Name:
*
Date of Birth
*
MM
1
2
3
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5
6
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DD
1
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YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2002
2001
2000
1999
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
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1930
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1928
1927
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1925
1924
1923
1922
1921
1920
Current Age
*
Hidden
Contact Info
Contact Info
Please fill in the remaining questions below with your own contact information
Your Full Legal Name:
First Name
*
Middle Name
Last Name
*
Marital Status
*
Single
Married
Separated
Divorced
Widowed
If you have a different last name that may be on your medical records, please list it here:
Email
Cell Number
*
Address
*
Street Address
City
ZIP / Postal Code
State
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Are you currently represented by another law firm to pursue legal action for your baby carrier case?
*
Note: This does not pertain to any suit against a doctor or hospital/facility.
Yes
No
Amazing! We're so happy that you're standing up for yourself, and everyone hurt by harmful baby carriers. You can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.
Great! We're so happy you're interested in standing up for yourself, and everyone hurt by harmful baby carriers. Just so you know, you can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.
IPQS
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