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PPA (Phenylpropanolamine)

Do I have a case?

Do I have a Case?

If you would like more information on pursuing a claim for damages due to PPA (Phenylpropanolamine), please fill out the form below. There is no charge for this evaluation.

* Required Fields.

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Title*: First Name*: MI Last Name*:

E-mail Address*:
(ex. johndoe@anywhere.com)

Home Phone*: (ex. 505-555-5005)

Work Phone: (ex. 505-555-5005)

Mobile Phone:
(ex. 505-555-5005)

Street Address:

City:

State / Zip: / (ex. NY / 10005)

Drug Information

In what state was the drug prescribed?

What date did you start taking the drug?

What date did you stop taking the drug?

What dosage were you prescribed?

When did you have a stroke?

When was the last time before your stroke that you took PPA?

What is the name (including brand name), dosage, and how frequently you took the medicine:

List all other medications you were taking when you took PPA:

Please describe circumstances involving your stroke:

List any other problems you developed while taking PPA:

Did a doctor ever tell you that you were injured as a result of taking PPA:

Yes No

If so, when:

Additional Information

Do you currently have an attorney who represents you on behalf of your PPA claim? Yes No

Attorney's Name:

Address:

City:

State:

Zip:

Other Information:

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