DIAGNOSED WITH GBS?
Take THE SURVEY now!
Please enable JavaScript in your browser to complete this form.
Have you been diagnosed with Guillain Barre Syndrome (“GBS”)?
*
Yes
No
Have you received a vaccine in the past 3 years?
*
Yes
No
Did your symptoms begin sometime after you received a vaccine?
Yes
No
If yes, which vaccine?
*
Seasonal influenza (e.g., Flu)
Diphtheria (e.g., DTaP)
Hepatitis A
Hepatitis B
COVID-19
Human papillomavirus (e.g., HPV)
Other
Have you ever considered the link between vaccines and GBS or discussed this with your doctor?
Yes
No
Approximate month/year you received the vaccine in question:
*
Approximate month/year you started experiencing GBS symptoms:
*
Based on your responses, it is possible that your GBS diagnosis may be due to a vaccine. You may be entitled to significant compensation through the Vaccine Injury Compensation Program.
Click here
to call us now to discuss your potential claim OR simply click Submit and your survey information will be routed to our GBS vaccine injury team. We provide a FREE EVALUATION of your potential claim and NO COST representation if your case is accepted
Based on your responses, it does not appear your GBS diagnosis was related to a vaccine you received in the past three years, which is typically a pre-requisite for filing a claim for relied in the national vaccine injury compensation program.
What is your first and last name?
*
First
Last
What is your email?
*
What is your phone number?
*
Submitting this form does not create an attorney-client relationship between you and the attorneys of Siri & Glimstad LLP. We may collect, use, and process your data according to the terms of our
Privacy Policy
.
Name
SUBMIT
ATTORNEY ADVERTISEMENT. DOES NOT CONSTITUTE MEDICAL OR LEGAL ADVICE.
→
Contact Us
