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Lotronex

Do I have a case?

Do I have a Case?

If you are not currently involved in litigation related to problems with Lotronex then we can help you. Send the required information using the form below and we will contact you to discuss your options.

* Required Fields.

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First Name:*

Last Name:*

Street Address:

City:

State:

Zip:

Email:*

Daytime Phone:*

Evening Phone:

Date of Birth:

(01-01-2000)

Drug Information

Describe medical history for Gastrointestinal Disease prior
to LOTRONEX Use:

Physician Name/Address who prescribed LOTRONEX:

Date Started LOTRONEX:		(Ex. 02/01/01)
Date Ended LOTRONEX:		(Ex. 02/01/01)
Dosage of LOTRONEX You Were Prescribed:

List any problems you developed while you were taking LOTRONEX:

When did you first suspect that you had adverse effects as a result of taking LOTRONEX?

Did a doctor ever tell you that you were injured as a result of taking LOTRONEX: Yes No

If so, when?:

(Ex. 10/12/01)

Have you had any other testing or treatment as a result of taking this medication: Yes No

If so, describe what kind of tests or treatment and results:

Additional Information

Do you currently have an attorney who represents you on your LOTRONEX claim? Yes No

Attorney's Name:
Address:
City:
State:
Zip:

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