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Pharmaceutical Litigation Form

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Pharmaceutical Litigation Case Form

NOTE:  An Asterisk (*) Indicates REQUIRED Information.

*Full Name:

  

Home Address:

City:

State:

Zip:

Phone Number:

  

*E-mail Address:
 

What is the name of the medication you took?


 

Where, when and by whom was the medication purchased?


 

Was this medication prescribed or over-the-counter?


 

Where, when and by whom was the medication prescribed (if applicable)?


 

How much/how long did you take the drug?


 

What problems resulted from taking the drug and have you received any medical care or treatment for the problems?


 
   

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