Form

1201 Pacific Avenue, Suite 600

Tacoma, WA 98402-4384

Baby Formula Intake Form

The baby formula manufacturers have allegedly known about the increased risk of NEC for premature infants who consume cow’s milk-based formula but failed to properly warn about the risks. This medical condition causes intestinal tissue to die and may lead to other serious health problems.

Manufactures:

Abbott Laboratories (Similac)
Mead Johnson (Enfamil)

CRITERIA:

Diagnosis of NEC (necrotizing enterocolitis)
Born premature
Birth 2004 or later

First Name*

Middle Name

Last Name*

DOB*

Month/Day/Year

Email*

Phone number*

Street address*

City*

State/Region*

Postal code*

Caller’s Relationship to Injured Person:

Is the Physical Address Different Than the Address Above?

Child's Information

Has Your Baby/Child Been Diagnosed With Necrotizing Enterocolitis (NEC)?*

Child's Name:*

If NO, DECLINE

Was Your Child Born Prematurely?*

Is Child Deceased?*

Formula History

Was Your Baby Given Similac or Enfamil While in the Hospital?*

Name of the Hospital:*

Location of Hospital:

When discharged home, did you feed your baby one of the following formulas?*

Enfamil Human Milk Fortifier Acidified Liquid

Enfamil 24 and DHA & ARA Supplement

Enfamil Human Milk Fortifier Powder

Similac Special Care 30

Similac Human Milk Fortifier Hydrolyzed Protein- Concentrated Liquid

Enfacare Powder

Enfamil Human Milk Fortifier Liquid High Protein

Enfamil Milk Fortifier Liquid Standard Protein

Enfamil NeuroPro Enfacare

Enfamil Premature 20 Cal

Enfamil Premature 24 Cal

Enfamil Premature 24 Cal/fl oz HP

Enfamil Premature 30 Cal

Similac Special Care

Similac Human Milk Fortifier

Similac NeoSure

Similac Alimentum

Similac Alimentum Expert Care

Similac Human Milk Fortifier Concentrated Liquid

Similac Human Milk Fortifier Powder

Similac Liquid Protein Fortifier

Similac Special Care 20

Similac Special Care 24

Similac Special Care 24 High Protein

Please Save ALL Evidence

Includes: any proof of purchase, receipts, packaging, boxes, etc.
Click the SUBMIT button when you have finished.