Tylenol Fact Sheet - Dovel & Luner

If you have a child diagnosed with autism or ADHD and would like to speak with our firm about representation in a lawsuit against the companies that make and sell Tylenol and acetaminophen, please answer the questions in the form below.

You should know that our work is on a contingency fee basis, which means that the client will not owe any fees or costs unless there is a financial recovery for the client.

Personal Information (Person Filling Out Form)

Legal Name:

Address:

Mobile Phone:

Email:

Relation to the Child:

Drug Information

Please list all retailers where the mother purchased the drug:

Did the mother get approval from a doctor to ingest Tylenol/Acetaminophen?

When the mother took Tylenol/Acetaminophen, what amount did the mother normally take?

Why did the mother take Tylenol/Acetaminophen?

How frequently did the mother take Tylenol/Acetaminophen during the second trimester of the pregnancy?

How frequently did the mother take Tylenol/Acetaminophen during the third trimester of the pregnancy?

Please list the start and stop date of the mother's ingestion of the drug:

Diagnosis Information

Date of diagnosis of Autism Spectrum Disorder and/or Attention-Deficit Hyperactivity Disorder:

Diagnosing Facility Name:

Diagnosing Facility City:

Diagnosing Facility State:

When did the mother learn that the child's Autism/ADHD could be related to Tylenol/Acetaminophen?

If yes, please provide the other conditions:

If yes, please describe the accommodation:

Labor & Delivery Information

OBGYN Name or Facility at the time of birth:

OBGYN or Facility Address:

OBGYN or Facility City:

OBGYN or Facility State:

Date of Childbirth:

Name of Hospital:

City of Hospital:

State of Hospital:

Please list any other facility where the mother received pre-natal care:

How was the baby delivered?

If yes, what complications?

Additional Information

Child Information

Child's Legal Name:

Child's Date of Birth:

Last Four Digits of SSN:

Who has legal custody of the child with Autism/ADHD?

Child's Primary Language:

Please list all schools the child attended (including name and years attended):

Please list treatment courses, therapies, special needs programs, etc. that the child attended from birth to present day (i.e. Speech Therapy, Occupational Therapy, etc.):

Please list all facilities and providers from which the child received care for all medical concerns (from birth to present day):

Please list all medical prescriptions written for the child for all medical concerns and any pharmacies (from birth to present day):

If the child was given Tylenol or Acetaminophen between birth and age three, how often was it given and why:

Mother's Information

Mother’s Legal Name:

Mother's Date of Birth:

Mother’s Email Address:

Mother’s Phone Number:

Mother’s Address:

Mother's Primary Language:

Please list the address of the mother's primary residence during pregnancy:

Does the family have a history of Autism/ADHD/developmental delays? (include the diagnosis and relation to the mother and/or child):