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PERSCRIPTION MEDICATION LAWSUIT CLAIMS

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Claim Evaluation Form
Fields marked with an * are required.
* Name  

 Address

 

City

 

  State

 

Zip Code

 

* Phone

 

Phone 2

 

Best Time to Call

 

Email Address

 

Side Effects

Heart Attack
Heart Failure
Stroke
No know side effects to date

How long were you or a loved one on the medication?:

Less than one year
More than one year
Don't know
* What health effects have you suffered?
When did they take place?
Comment on any medication use?


I agree that the above is not a request for legal advice and that I am not forming an attorney client relationship. 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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