Skip to main content
Close Search
Menu
About Us
How It Works
FAQs
Foundation
Attorneys Only
Blog
Menu
A CASE FOR WOMEN – Injectafer Questions
Questions? Call us at
(888) 373-7888
.
Step
1
of
5
0%
This is a unique url created just for you. If you would like to share this process with others, please direct them to our website, but do not share this link.
PERSONAL AND CONFIDENTIAL – PROSPECTIVE CLIENT COMMUNICATION
Injectafer Questions
Are you contacting us on behalf of someone else?
*
Yes
No
Is that person deceased?
*
Yes
No
When did they pass away?
If you are unsure, an approximate date is fine.
Month deceased
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year deceased
*
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
What was their cause of death?
*
Do you have a copy of the death certificate that you could provide the firm?
*
Please note, you do not need to provide those documents to us at this time, but you will need to provide your firm a copy of it.
Yes
No
Do you have paperwork proving that you have power of attorney status?
*
Please note, you do not need to provide those documents to us at this time, but you will need to provide your firm a copy of it.
Yes
No
Do any of the following apply?
Executor of their estate
Power of attorney
Next of kin
Other
Please explain:
Legal Name of the person you are contacting on behalf of:
Their First Name
*
Their Middle Name
Their Last Name
*
Their 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
Their relationship to you:
Injectafer Use
Were you given Injectafer or an Iron IV “intravenous”?
*
Yes
No
Please explain:
*
How many times were you given Injectafer?
*
Hidden
[DEL]If you were given Injectafer more than once, how many days apart were the first two doses?
If you were given Injectafer more than once, how many days apart were the first two doses?
*
-select-
1 day apart (for ex - Mon, Tues)
3 days apart (for ex - Mon, Friday)
Between 4 to 6 days apart
7 days apart
More than one week apart
More than one month apart
Was only given Injectafer once
Other
Please explain:
*
When were you first given Injectafer?
If you are unsure, an approximate date is fine.
Month first given
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year first given
*
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
When were you last given Injectafer?
If you are unsure, an approximate date is fine.
Month last given
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year last given
*
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
Why were you given Injectafer?
*
Are you aware of any of your serum phosphate (or phosphorous) levels that were recorded within 1 month after your Injectafer use?
*
Yes
No
Was it ever – at any point – lower than 2.0 mg/dl?
*
Yes
No
After you had Injectafer, when did you get your phosphorous measures done?
If you are unsure, an approximate date is fine.
Month measured
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year measured
*
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
What state were you given Injectafer in?
*
- 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
What facility did you receive Injectafer in?
*
Please list the address and/or hospital name.
Injectafer Use
Were they given Injectafer or an Iron IV “intravenous”?
*
Yes
No
Please explain:
*
How many times were they given Injectafer?
*
Hidden
[DEL]If they were given Injectafer more than once, how many days apart were the first two doses?
If they were given Injectafer more than once, how many days apart were the first two doses?
-select-
1 day apart (for ex - Mon, Tues)
3 days apart (for ex - Mon, Friday)
Between 4 to 6 days apart
7 days apart
More than one week apart
More than one month apart
Was only given Injectafer once
Other
Please explain:
*
When were they first given Injectafer?
If you are unsure, an approximate date is fine.
Month first given
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year first given
*
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
When were they last given Injectafer?
If you are unsure, an approximate date is fine.
Month last given
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year last given
*
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
Why were they given Injectafer?
*
Are you aware of any of their serum phosphate (or phosphorous) levels that were recorded within 1 month after their Injectafer use?
*
Yes
No
Was it ever – at any point – lower than 2.0 mg/dl?
*
Yes
No
After they had Injectafer, when did they get their phosphorous measures done?
If you are unsure, an approximate date is fine.
Month measured
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year measured
*
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
What state were they given Injectafer in?
*
-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
What facility did they receive Injectafer in?
*
Please list the address and/or hospital name.
Prescription Details
When were you prescribed Injectafer?
If you are unsure, an approximate date is fine.
Month prescribed
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year prescribed
*
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:
Facility:
*
Prescription Details
When were they prescribed Injectafer?
If you are unsure, an approximate date is fine.
Month prescribed
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year prescribed
*
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:
Facility:
*
Medical Info
Hidden
(Dep) Did you receive medical attention for any of the following after using Injectafer?
Hypophosphatemia or Severe Hypophosphatemia
Renal Phosphate Wasting
Drop in blood phosphorus/phosphate levels
Severe muscle fatigue or weakness
Severe fatigue
Severe or extended Pain
Respiratory Failure
Rhabdomyolysis (death of muscle tissue)
Acute renal failure
Osteomalacia (also known as softening of bones)
Bone fractures or bone pain
Cardiac arrhythmias or dysrhythmias
Cardiac arrest or failure
Other
None of the above
After receiving Injectafer, did you experience any of the following symptoms?
*
Please check all that apply:
Hypophosphatemia or Severe Hypophosphatemia
Renal Phosphate Wasting
Drop in blood phosphorus/phosphate levels
Severe muscle fatigue or weakness
Severe fatigue
Severe or extended Pain
Respiratory Failure
Rhabdomyolysis (death of muscle tissue)
Acute renal failure
Osteomalacia (also known as softening of bones)
Bone fractures
Bone pain
Cardiac arrhythmias or dysrhythmias
Cardiac arrest or failure
Other
None of the above
Please explain:
*
Did you have any prior history of this?
*
Yes
No
Please explain:
*
Are you in need of immediate medical attention for any symptoms?
*
Yes; I have an upcoming appointment
No
I haven’t gone to the doctor yet but I intend to
Date of next doctor appointment:
If you are unsure, an approximate date is fine.
Month:
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year:
*
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:
*
Any other details?
Medical Info
Hidden
(Dep) Did they receive medical attention for any of the following after using Injectafer?
Hypophosphatemia or Severe Hypophosphatemia
Renal Phosphate Wasting
Drop in blood phosphorus/phosphate levels
Severe muscle fatigue or weakness
Severe fatigue
Severe or extended Pain
Respiratory Failure
Rhabdomyolysis (death of muscle tissue)
Acute renal failure
Osteomalacia (also known as softening of bones)
Bone fractures or bone pain
Cardiac arrhythmias or dysrhythmias
Cardiac arrest or failure
Other
None of the above
After receiving Injectafer, did they experience any of the following symptoms?
Please check all that apply:
Hypophosphatemia or Severe Hypophosphatemia
Renal Phosphate Wasting
Drop in blood phosphorus/phosphate levels
Severe muscle fatigue or weakness
Severe fatigue
Severe or extended Pain
Respiratory Failure
Rhabdomyolysis (death of muscle tissue)
Acute renal failure
Osteomalacia (also known as softening of bones)
Bone fractures
Bone pain
Cardiac arrhythmias or dysrhythmias
Cardiac arrest or failure
Other
None of the above
Please explain:
*
Did they have any prior history of this?
*
Yes
No
Please explain:
*
Are they in need of immediate medical attention for any symptoms?
*
Yes; They have an upcoming appointment
No
They haven’t gone to the doctor yet but they intend to
Date of next doctor appointment:
If you are unsure, an approximate date is fine.
Month next appointment
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year next appointment
*
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:
*
Any other details?
Medical Details
Please answer the following questions as relates only to any symptoms or side effects you experienced after Injectafer usage.
When did your symptoms begin?
If you are unsure, an approximate date is fine.
MonthSymptomsBegan
*
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
YearSymptomsBegan
*
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
What kind of medical treatment did you receive for the side effects you experienced after your Injectafer treatment?
*
Hidden
Month of treatment
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Hidden
Year of treatment
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
Please list the dates of treatment received. If you received medical care more than once, or for more than one symptom, please list each separate instance.
*
Hidden
(Dep) Doctor:
Doctor:
*
Hidden
(Dep) What did the doctor say?
(Was there a diagnosis? Did they give any explanation for your symptoms?)
What did the doctor say?
(Was there a diagnosis? Did they give any explanation for your symptoms?)
Hidden
(Dep) Name and address of treatment facility:
Name and address of treatment facility:
*
Did the side effects you experienced from Injectafer infusions improve or go away after a few weeks?
*
Yes
No
Did any healthcare provider tell you this injury could be Injectafer related?
*
Yes
No
Please explain/list doctor if possible
What is your current medical condition? Do you have any new symptoms you have experienced?
Did you weigh less than 110 lbs at the time of Injectafer treatment?
*
Yes
No
Hidden
(Dep) In the 12 months leading up to your Injectafer treatment, were you diagnosed with any of the following?
Vitamin D deficiency
Parathyroid hormone disturbance (PTH) or hyperparathyroidism
Low phosphorous dx and/or taking phosphorous supplements
Refeeding syndrome
Chronic kidney disease and/or on dialysis
Colon Cancer
Alcoholism or alcohol abuse?
In the 12 months leading up to your Injectafer treatment, were you diagnosed with any of the following?
*
Vitamin D deficiency
Parathyroid hormone disturbance (PTH) or hyperparathyroidism
Low phosphorous dx and/or taking phosphorous supplements
Refeeding syndrome
Chronic kidney disease and/or on dialysis
Colon Cancer
Alcoholism or alcohol abuse?
None of the Above
Had you stopped dialysis at least 6 months before Injectafer use?
*
Yes
No
Medical Details
Please answer the following questions as relates only to any symptoms or side effects they experienced after Injectafer usage.
When did their symptoms begin?
If you are unsure, an approximate date is fine.
MonthSymptomsBeganCBH
*
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
YearSymptomsBeganCBH
*
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
What kind of medical treatment did they receive for the side effects they experienced after their Injectafer treatment?
*
Hidden
[DEL]Month of treatment
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Hidden
[DEL]Year of treatment
*
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
Please list the dates of treatment received. If you received medical care more than once, or for more than one symptom, please list each separate instance.
*
Hidden
(Dep) Doctor:
Doctor:
*
Hidden
(Dep) What did the doctor say?
(Was there a diagnosis? Did they give any explanation for their symptoms?)
What did the doctor say?
(Was there a diagnosis? Did they give any explanation for their symptoms?)
Hidden
(Dep) Name and address of treatment facility:
Name and address of treatment facility:
*
Did the side effects they experienced from Injectafer infusions improve or go away after a few weeks?
*
Yes
No
Did any healthcare provider tell them this injury could be Injectafer related?
*
Yes
No
Please explain/list doctor if possible
What is their current medical condition? Do they have any new symptoms they have experienced?
Did they weigh less than 110 lbs at the time of Injectafer treatment?
*
Yes
No
Hidden
(Dep) In the 12 months leading up to their Injectafer treatment, were they diagnosed with any of the following?
Vitamin D deficiency
Parathyroid hormone disturbance (PTH) or hyperparathyroidism
Low phosphorous dx and/or taking phosphorous supplements
Refeeding syndrome
Chronic kidney disease and/or on dialysis
Colon Cancer
Alcoholism or alcohol abuse?
In the 12 months leading up to their Injectafer treatment, were they diagnosed with any of the following?
*
Vitamin D deficiency
Parathyroid hormone disturbance (PTH) or hyperparathyroidism
Low phosphorous dx and/or taking phosphorous supplements
Refeeding syndrome
Chronic kidney disease and/or on dialysis
Colon Cancer
Alcoholism or alcohol abuse?
None of the Above
Had you stopped dialysis at least 6 months before Injectafer use?
*
Yes
No
Job/Occupation:
Did you have to stop working or take time off work because of your symptoms?
*
Yes
No
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:
Do you possess copies of your medical records that relate to Injectafer and your related symptoms/treatment?
Yes
No
Unsure
Anything else we should know?
Job/Occupation:
Did they have to stop working or take time off work because of your symptoms?
*
Yes
No
Their Marital Status
*
Single
Married
Separated
Divorced
Widowed
If they have a different last name that may be on their medical records, please list it here:
Do you possess copies of their medical records that relate to Injectafer and their related symptoms/treatment?
Yes
No
Unsure
Anything else we should know?
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
*
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
If we are unable to reach you, do you have an alternate or emergency contact we can reach out to?
Please give their name and relationship to you:
Their phone number:
Their email address:
If we can’t reach you, is it okay for us to reach out privately via social media?
Yes
No
Please list the social media platform and your username:
Are you currently represented by another law firm to pursue legal action for your Injectafer 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 Injectafer. 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 Injectafer. 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
Comments
This field is for validation purposes and should be left unchanged.
Close Menu
About Us
How It Works
FAQs
Foundation
Attorneys Only
Blog
#icouldntsayno
Baby Food Metals
Birth Injury
California Sexual Abuse
Camp Lejeune
Cannabis Vapes
Catholic Church Abuse
Chemical Hair Relaxers
CooperSurgical IVF
Dr. Ortega Sexual Assault
Elmiron
Equal Pay
Essure
Gel Nails
Hernia Mesh
Huck Sexual Abuse
JUUL E-cigarettes
Latter-Day Saints Abuse
Long-Term Care Abuse
Massage Envy
Mesothelioma
NEC
Ozempic
Paragard
Roundup
Real Estate Sexual Assault
Sex Trafficking
Sexual Harassment
Soccer Abuse
Talcum Powder
Troubled Teen Industry
Uber Sexual Assault