REQUEST MORE INFORMATION  

First Name:
Last Name:
E-mail:
Phone:
Address:
 
City:
State:
Zipcode:
Have any of the following complications occurred:
Liver Failure
Hospitalization
Stroke
Death

 Heart Attack
Kidney Disease
Liver Transplant
Other Serious Injury
Please describe any complications:
Please select all products taken:
Hydroxycut Regular Rapid Release Caplets
Hydroxycut Caffeine-Free Rapid Release Caplets
Hydroxycut Hardcore Liquid Caplets
Hydroxycut Max Liquid Caplets
Hydroxycut Regular Drink Packets
Hydroxycut Caffeine-Free Drink Packets
Hydroxycut Hardcore Drink Packets (Ignition Stix)
Hydroxycut Max Drink Packets
Hydroxycut Liquid Shots
Hydroxycut Hardcore RTDs (Ready-to-Drink)
Hydroxycut Max Aqua Shed
Hydroxycut 24
Hydroxycut Carb Control
Hydroxycut Natural
Other (please explain below)
Where was the Hydroxycut product purchased?
GNC
Wal-Mart
 The Vitamin Store
Other (list below)
Other comments/questions:
Philadelphia Lawyers - Pennsylvania Lawsuits at Monheit Law

Law Offices of Michael Monheit 1368 Barrowdale Road  Rydal, PA  19046
Call Us Toll Free: 866-761-1385  P: 215-840-6573  E: Michael@Monheit.com

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