VIOXX Questionaire

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VIOXX Questionnaire

Please provide the following information

Title
First Name
MI
Last Name
E-mail
Retype E-mail
Home Phone
Mobile Phone
Work Phone
Dates Drug Taken
Prescribed by Whom?
Dosage?
Have you suffered
a heart attack?
Yes No
If so please provide details
Have you suffered a stroke? Yes No
If so please provide details
Age
Date of Birth

 

I agree that this matter may be referred to an attorney who may contact me.

Yes No

 

I agree that by submitting this query and/or question I will not be
charged for the response. I also understand that I am not forming an attorney-client relationship with your law firm.

Yes No

 

I agree that the above does not constitute a request for legal advice. I understand that I may retain your firm's services by entering into a fee agreement, and that I am not now entering into such an agreement. I agree that the information that I will receive from you in answer to the above question is general information only and without charge. I further understand that the law for each state is different, and I will not rely upon this information as legal advice.
 

By Clicking on the appropriate box below I signify and agree to

 

 

 

 

 

 

 

   

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