Were you diagnosed with Brain Meningioma after using
Depo-Provera for at least one year?

This helps determine whether your diagnosis may meet the
initial case requirements.

• 🩺 The diagnosis must be Brain Meningioma

• ⏳ Depo-Provera must have been used for at least one year before diagnosis

• 🔒 Your medical information is private and secure

• ✅ Please answer accurately

Did you receive at least 4 Depo-Provera injections?

Four injections are treated as approximately one year of
Depo-Provera use.

• 💉 At least 4 injections are required

• ⏳ This generally represents one year of use

• 🔒 Your answers are kept private

• ✅ Accurate information avoids delays

Were you diagnosed between 1992 and the present?

Your Brain Meningioma diagnosis must have occurred during
this period.

• 📅 The diagnosis must be from 1992 to the present

• 🩺 Use the date shown in your medical records

• 🔒 Information is used only for case screening

• ✅ Answer honestly

Did you use Depo-Provera between January 1, 1992 and
December 31, 2019?

At least part of your qualifying Depo-Provera use must fall
within this period.

• 📅 Required use period: 01/01/1992–12/31/2019

• 💉 Check prescription or injection records when available

• 🔒 Your information remains private

• ✅ Accurate dates help evaluate your claim

Are your symptoms or injury within 90 days of the statute
of limitations in Kentucky, Louisiana, Tennessee, or
Puerto Rico?

Select the answer that best reflects your situation.

• ⚖️ This question applies to KY, LA, TN, and PR

• 📅 Consider when your symptoms or injury were discovered

• 🔒 Your answer is used for initial screening

• ✅ Select “No” only when it is accurate

Has the statute of limitations expired in Alabama, Idaho,
Maine, Texas, New York, or Virginia?

Select the answer that best reflects your situation.

• ⚖️ This question applies to AL, ID, ME, TX, NY, and VA

• 📅 Statute-of-limitations rules vary by state

• 🔒 Your answer is private

• ✅ Please answer accurately

Are you currently being represented by an attorney for
this Depo-Provera claim?

We can generally assist only when you are not already
represented for the same claim.

• ⚖️ “No” means your claim may be evaluated

• 🤝 We will not interfere with existing representation

• 📝 Answer honestly to avoid delays

• 🔒 No obligation to proceed

What was the date of your Brain Meningioma diagnosis?

Enter the diagnosis date shown in your medical records.

Diagnosis Date

• 📅 This date is required by the case-review system

• 🩺 Use the date in your diagnosis records

• 🚫 A future date cannot be entered

• 🔒 Your information is handled securely

What are the last 4 digits of your Social Security Number?

Only the last four digits are required for identity
verification. Do not enter your complete Social Security
Number.

Last 4 digits of Social Security Number

• 🔢 Enter exactly four numbers

• 🚫 Do not enter your complete Social Security Number

• 🔐 Used only for identity and case verification

• ✅ This field is required by the case-review system

Please provide your name

Enter your legal name for proper documentation.

• 📝 Use your legal first and last name

• 🔐 Your details are protected

• 📧 Used for communication about your inquiry

• ✅ Correct spelling prevents delays

Please provide your email address and phone number

We will use these details to contact you about the next steps.

• 📧 Enter an email address you regularly check

• 📞 Enter a valid 10-digit U.S. phone number

• 🔔 You may be contacted if your inquiry qualifies

• 🔒 Your contact details are kept private

What is your ZIP Code?

Your ZIP Code helps confirm location-based eligibility.

• 📍 Enter a valid 5-digit ZIP Code

• 🧭 Used to determine location-based availability

• 🔒 Kept private and secure

• ✅ Accurate information prevents delays

Is there anything else we should know about your case?

Add any details that may help with the initial review.