Request for Information About Making a RhoGAM® Claim

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RhoGAM® Case Review Form

Thank you for your interest in Brayton Purcell. Please fill out this form to receive information and a free case evaluation if you received RhoGAM® injections during pregnancy and your child was born with nervous system problems. Responding to the form questions will only take a few minutes of your time.

The fields marked below with an asterisk (*) are required.


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  1. Did you receive RhoGAM® injections during a pregnancy?*
  1. Did you receive flu shots during a pregnancy?
  1. Please provide names and birth dates of children.*
  1. Have any of your children been diagnosed with any of the listed diseases? Select all that apply:
  1. Please add any comments about your children’s injuries.
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