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Pharmaceutical Litigation Evaluation

First Name:
Last Name:
Email Address:
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Street Address:
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What is the best way to reach you? Please provide the best place, time and method for contacting you.
What prescription medication are you inquiring about?	Other:
How long was the medication taken?
When did you start taking the prescription?
When did you stop taking the prescription?
Your date of birth:
Please list any medical conditions you had prior to taking the medication:
Please tell us why the medication was prescribed:
Have you suffered any serious medical side effects since taking this medication?	Yes No
Please describe your side effects:
Have you suffered any cardiovascular problems?	Yes No
Were you taking any additional medications?	Yes No
If so, please list other medications:
How did you hear about us?
I understand that by submitting this form I am not retaining a lawyer. Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal "retainer agreement."

Past results afford no guarantee of future results and each case is different and is judged on its own merits. Some cases result in no recovery. Costs and expenses will be advanced and reimbursed to us only if you recover. You have no liability for costs or expenses unless a court directs. The choice of a lawyer is an important decision and should not be based solely upon advertisements. Some matters may be referred to other lawyers. Neither the Supreme Court of Missouri nor the Missouri Bar reviews or approves certifying organizations or specialist designations. Never stop taking any prescription drug without first consulting with a doctor. Not available in all states.
Areas We Serve: Kansas City (MO), Overland Park (KS), Lee's Summit (MO), Independence (MO), Liberty (MO), St. Joseph (MO), Leavenworth (KS), Lansing (KS), Atchison (KS), Kearney (MO), Lawrence (KS), Topeka (KS), Olathe (KS), Bethany (MO), Falls City (KS), Columbia (MO).
Community: Missouri, Kansas, Kansas City (MO), Topeka (KS), St.Joseph (MO), Lawrence (KS), Columbia (MO), Springfield (MO), Jasper County (MO), Green County (MO), Springfield County (MO), Buchanan County (MO)