Free Case Evaluation

Please be assured that the information you provide to our law firm when completing this legal case evaluation form will be treated by us as strictly confidential. You will get a reply from us no later than the next business day. Submitting a case evaluation does not obligate you to hire our law firm for your lawsuit. We handle all cases on a contingency fee basis, which means that you will make no payment for our legal services until after we have succeeded in getting legal compensation for you.

Personal Information

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Best time to call:	Day Night
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Case Facts

1.	Have you, a family member, or some other person you know suffered a serious side effect which may have been caused by Avandia? Yes No
	If yes, please indicate which condition(s) the doctor diagnosed; check all that apply: Heart Attack (Myocardial Infarction) Stroke (Cerebrovascular Accident or CVA) Congestive Heart Failure (CHF) Cardiovascular Death Liver Failure Hepatitis
	Other adverse side effects:
2.	Would the case you are describing be a personal injury case or a wrongful death case? Personal Injury Wrongful Death
3.	Is this for you or someone else, and if it is for someone else, what is his or her relationship to you? Me Someone Else
	If for someone else, what is your relationship:
4.	What was the date of the initial diagnosis of the Avandia side effect?
5.	If there was a death from Avandia, on what date did it occur?
6.	What is the date of birth of the person who had an adverse reaction to Avandia?
7.	Has a lawsuit been filed concerning the Avandia side effect? Yes No
8.	What dosage of Avandia was prescribed?
9.	Is there any additional information you would like to include?

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