If you would like us to review your case, please take a moment to tell us what happened. We will contact you within 48 hours to let you know if we can help.

Bextra Evaluation
* All indicated fields must be completed.

First Name:

Last Name:

Address:

City, State, Zip Code:

Work Phone:

Cell Phone:

*E-mail Address:

Date of Birth:(mm/dd/yy)

Why was Bextra prescribed?

Were you on Bextra Daily or other?

What dosage of Bextra were you prescribed (i.e., 25mg, 50mg, 75mg)?

How long have you been on Bextra? (Start Date to End Date)

Did Effects from Bextra Include (Heart Attack, Stroke, Deep Vein Thromobosis, Blood Clots, Pulmonary Embolism, Other)?

Nature of Treatment Received?

Name of Treating Physician?

What other Medications are you on?

How did you hear about our firm?
(where did you see the Ad)
   

IIMPORTANT: An attorney client relationship is not established by sending us this e-mail. Such a relationship is established only after we have had the opportunity to review the facts surrounding your case and have spoken to you personally about the matter.