Depo-Provera Pre-Qualification Form

First name

Last name

Email

Mobile Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of Birth

Did you receive FOUR or more consecutive (back-to-back) Depo-Provera injections within a year?

Yes

No

What brand did you use?

Depo-Provera (brand name)

Generic version: Greenstone (Pfizer subsidiary), Viatris, Prasco Labs

Medroxyprogesterone acetate

Unsure (Please have your prescription name available when we contact you)

Have you been diagnosed with meningioma (brain tumor)?

Yes

No

Are you already represented by an attorney regarding this matter OR have you previously worked with an attorney in the past for this matter?

Yes

No

I confirm that all information provided is truthful and accurate. I understand that my claim will require verification through medical records, identification, and any other supporting documentation. Providing false information will result in immediate disqualification.

I consent to being contacted by Poca Lead Logic by phone, email or text regarding my potential claim.

You Went In for a Shot to Protect Yourself and Left With Problems.