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Pharmaceutical Litigation

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Pharmaceutical Litigation Evaluation

First  Name:
Last Name:
Email Address:
Home Phone: - -
Cell Phone: - -
Work Phone: - - ext.
Street Address:
Address #2:
City:
State/Zip: /
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."


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