First and Last Name (required):
Email (required):
Mailing Address:
Alternate Contact Name:
Alternate Contact Phone:
Did you purchase a dozen or the 2.5 dozen egg carton of Gravel Ridge Farms eggs? YesNo
Did you eat an egg or eggs from the carton? If so, who? YesNo
Did you develop diarrhea, fever, and abdominal cramps? YesNo
Did others, if any, develop diarrhea, fever, and abdominal cramps? YesNo
Were you treated at the emergency room? YesNo
Where did you purchase the egg carton? Candler Park MarketGrant Park MarketWestview Corner MarketSevananda Natural FoodsThe MerchantileBirminghamPiggly Wiggly ClairemontPiggly Wiggly River RunPiggly Wiggly CrestlinePiggly Wiggly Bluff ParkPiggly Wiggly Dunnavent ValleyPiggly Wiggly WarriorPiggly Wiggly HomewoodWestern Market Mt. BrookWestern Market Rocky RidgeFoodland EvaWarehouse Discount Grocery HancevilleWarehouse Discount Grocery Cullman - 2 locationsFoodland PricevilleStar Market HuntsvilleManna Grocery Tuscaloosa
Other:
When was the purchase made? Within the past 3 monthswithin the past 6 monthsmore than 6 months ago or more than a year ago
Did you make the purchase with a credit or debit card? YesNo
Do you have Receipt of Purchase? YesNo
Have you notified the company? YesNo
When did your injury occur?
Describe Incident and Your Injuries:
Do you have health insurance (Blue Cross, Aetna, Medicare, Medicaid, etc.)? YesNo
If yes, what is the name of the health insurance company:
Did you go to the Emergency Room? YesNo
If yes, where you taken by Ambulance? YesNo
From which ER did you receive treatment?
Do you have a General Treating Clinic or Physician? YesNo
If yes, who is your General Treating Clinic or Physician.
Have you received other medical treatment? YesNo
If yes, please name each hospital, doctor, physical therapist, etc., where you received treatment regarding this incident.
Have you talked to an Insurance Claims Adjustor? YesNo
If yes, what is their name and the name of their company.
Have you signed any paperwork from an insurance company or egg distributor since your since your infectious disease? YesNo
If you have signed paperwork, do you still have a copy of what you signed? YesNo
Have you received any compensation for the accident? YesNo
If so, who paid you the compensation?
How much was the compensation?
Are you currently taking medication? YesNo
If yes, what is type?
Where do you have this medication filled?
Do you know the total of your current medical bills? YesNo
if yes, how much are they?
ER Hospital Bill Ambulance Bill General Doctor's Bill Co-Pays Mileage Costs Time Spent in the Emergency Room Time Spent at the Doctor's Office Pharmacy Bills Other Bills Incurred Because of the Accident
Have you had any surgeries prior to the accident? YesNo
If yes, what were they for and when?
What other, if any, medical problems did you have before this infectious disease?
Did you miss any time from work because of the infectious disease? YesNo
If yes, how much time have you missed from work?
How much do you make per hour or per pay period?
Was your husband, a friend or a relative required to miss work to help you because of your accident or injury? YesNo
Are you on Social Security Disability or SSI? YesNo
If yes, what is the basis of your benefits?
If yes, where and against who? Please provide the name and address?
How did you (the caller) hear about us?
Referral, if so, by who:
Who completed this online intake?
First and Last Name of Person Completing Form:
If you need additional medical treatment in the next 24-48 hours, will you agree to go get it? YesNo
