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Vaccine Injury Intake Form

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

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Please read before filling out the form:

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

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

* 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.

Intake form

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

Thanks for submitting!


"The courts are our last line of defense. Without them, nothing stands between us and tyranny."



Michael is a very honest lawyer who cares about his clients. He is not afraid to take cases to trial and will fight for what his clients deserve. He settled my case right before trial for more than I could have ever imagined.

- Jason R.

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