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Ortho Evra Information

Ortho Evra

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This free case review form is very long and detailed. Do not feel it is required to fill out all fields and provide answers to every question. Do the best that you can. The more information we receive, the easier it is for our qualified attorneys to determine whether or not you may have a viable case.

Contact Information
First Name*
Last Name
Home Phone*	- -
Work Phone*	- -
Cell Phone*	- -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip
Injured Person's Contact Information
The injured person is
First Name:
Last Name:
Home Phone:	- -
Work Phone:	- -
Cell Phone:	- -
Email Address:
Street Address:
City:
State/Zip
Date of Birth
Sex	Male Female
Ortho Evra Information
Did you or a loved on suffer and injury from using the Ortho Evra Birth Control Patch?	Yes No
What type of injury occurred?
When did the injury or death occur?
Were you or loved one hospitalized from your injury?	Yes No
If Yes, please list name of hospital
Were you or loved one treated with blood thinner therapy?	Yes No
Are you or loved one still being treated with blood thinner therapy?	Yes No
If death occured, what is listed as the cause of death on death certificate?
When did you or loved one begin using the Ortho Evra Birth Control Patch?
What proof do you have of using the Ortho Evra Birth Control Patch?
Pharmacy records?
Yes No
Records from doctor?
Yes No
Unused Patch	Yes No
None	Yes No
Other	Yes No
If other please describe

How did you learn about the Ortho Evra Birth Control Patch?

Please list the name of prescribing doctors/physicians
Were you given any written material by any doctor or physician about the Ortho Evra Birth Control Patch?	Yes No
Were you or loved one taking any other medication while using the Ortho Evra Birth Control Patch?	Yes No
If yes, please list other medications:

Did the injured person smoke while using the Ortho Evra Birth Control Patch?	Yes No
If yes, please describe smoking history

Was injured person ever diagnosed as suffering from hypertension?	Yes No
Do you or loved one currently have an attorney or law firm representing you with an Ortho Evra Birth Control Patch claim?	Yes No
Additional Comments or Questions:

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	b. I agree that submitting this form and the information contained within does not establish an attorney client relationship..
	b. I agree that my information will be reviewed by more than one attorney and/or law firm.
	d. 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.