MEDICATION COMPLICATIONS & SIDE EFFECTS
PROBLEM DRUGS
1-800-510-7862

If you believe that you or a loved one has been adversely affected by medication, please fill out the form below. Provide as much information as possible to speed the processing of your inquiry.
 
*Items are required.
There is no charge for this evaluation.
 
Contact Information:
*Title: *First Name: MI: *Last Name:
 
*E-mail Address:
*Retype E-mail:
Home Phone:
 - -
Mobile Phone: - -
Work Phone: - - ext.
  *Provide at least 1 phone number.
Street Address:
Apt/Suite:
City:
State/Zip: /
 
What is the best way to reach you?
Please provide the best place, time and method for contacting you.
 
Additional Contact Information:
Use this area to add country codes, foreign addresses, special instructions, etc.
Injured Person Information:
Date of Birth:
Whom are you inquiring on behalf of?
If you are NOT inquiring on your own behalf,
what is your relationship?
Is the person deceased? Yes No

If deceased, the cause of death
as stated on the death certificate: 

Date of Death:
Was there an autopsy performed? Yes  No  n/a
Case Information:

What medication was used?

During what period of time was the medication prescribed?
Start End

Why was the medication prescribed?

What dosage of the medication were you prescribed daily? (i.e. 25mg, 50mg, 75 mg)

List names/addresses of any doctors who prescribed the medication:


Did effects from the medication include:

Skin rash / blisters Yes No
Cancer / lymhomas / leukemias Yes No
Suicide Yes No
Infections Yes No
Liver problems / Hepatitis Yes No
Blood / Bone Marrow problems Yes No
Heart Attack Yes No
Heart Attack Yes No
Stroke Yes No
Blood Clots Yes No
Deep Vein Thrombosis Yes No
Pulmonary Embolism Yes No
Swelling Yes No
Heart Failure Yes No
Kidney Problems Yes No
Irregular Heart Rhythm Yes No
High Blood Pressure Yes No
Death Yes No


Other medical problems since the use of medication:

Other Information:

Disclaimers:
Yes No - I agree that this matter may be referred to an attorney in my area who may contact me.

Yes No - I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.


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to Pharmaceutical Litigators
Please note that you are not considered a client until you have signed a retainer agreement and we have accepted your case.