Avandia Intake Form

Injury Related Information

*Did you or loved one take Avandia for 3 months or more?
Yes  No 

*Age of Injured:

*Have you been a regular smoker within the past 3 years?
Yes  No 

*Have you been diagnosed with Hypertension or High Cholesterol?
Yes  No 

Did you or loved one suffer any of the following injuries?

*Heart Attack
Yes  No 

*Congestive Heart Failure
Yes  No 

*Macular Edema
Yes  No 

*Liver Failure
Yes  No 

*Broken Bones or Fractures in the Hands/Feet
Yes  No 

*Stroke
Yes  No 

*Did injury occur while taking Avandia?
Yes  No 

*Were you or loved one diagnosed with Heart Problems or Liver Damage prior to using Avandia?
Yes  No 

*Do you currently have legal representation for this particular case?
Yes  No 

*COMMENTS: Please list any other details or symptoms related to Avandia:

Contact Information

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Alt Phone:

Best time to reach:
AM  PM 

I agree that submitting this form and the information contained within does not establish an attorney client relationship.

I agree that my information will be reviewed by more than one attorney and/or law firm.

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.

The contents of this contact form are provided by and are the responsibility of the person posting the email communication. Your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in email communications is at your own risk.