Free Vioxx Case Evaluation

Your Personal Information:
Your First & Last Name:
E-Mail Address:
(Please Provide At Least One Phone Number Where We Can Contact You. )
Home Phone :
Work Phone:
Street Address
City, State, Zip	, ,
Injured Parties Medical / Case Information
Injured Parties Date Of Birth:
What Is The Injured Party's Name?
If The Injured Party Is NOT You, What Is Your Relationship To Them?
Is The Injured Party Deceased?	Yes: No:
If Deceased, What Is The Cause Of death stated On The Death Certificate:
If Deceased, What Was The Date Of Death?
Was An Autopsy Performed?	Yes: No:
Vioxx Specific Medical & Case Information:
When Was Vioxx Prescribed?	Start: End:
Why Was Vioxx Pescribed?
What Dosage Of Vioxx Were You Or The Injured Party Told To Take On A Daily Basis?
Please Provide The Name(s) & Address(es) Of The Doctor(s) That Prescribed Vioxx:
Did You Or Your Loved One Suffer Any Of The Following Ailments While Taking Vioxx? (Please Check All That Apply)
Heart Attack Stroke Deep Vein Thrombosis Blood Clots Pulmonary Embolism Kidney Problems Death Other
If You Have Had Any Additional Medical Problems Since You Began Taking Vioxx, Please List And Describe Them Here:
Aprox. What Date Did Your Medical Problems Begin?
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