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First Name
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Last Name
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Phone
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e.g. 555-555-5555
Email
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What type of birth injury are you concerned about?
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-- Select --
Delayed developmental milestones
Cerebral palsy
Erb’s palsy
Shoulder dystocia
Brachial plexus
Broken clavicle
Stillbirth
Other
Was mom injured during birth?
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Yes
No
Please provide a brief summary of what occurred:
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