Hormone Replacement Therapy Information

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Contact Information

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Case Information

Name of Drug

Start date
Stop Date
Is the drug still being taken?Yes No
While taking the drug were you taking any additional drugs or medications?Yes No
If yes, please list names of additional drugs
Please list the side effects you or loved one has experienced
Do you feel you or your loved one has been injured from the use of this drug?Yes No
What type of injury occurred?
If death occurred, please list cause of death on death certificate
Have you talked with another attorney or law firm about your potential case?Yes No
Please list names of attorneys and/or law firms
Do you currently have a law firm or attorney representing you with this lawsuit?Yes No
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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.