Pharmaceutical Injury Review Form

Improperly designed, manufactured, or labeled pharmaceutical drugs can cause serious injuries or death. The attorneys at Brown & Crouppen can help you make informed decisions about your legal rights. Call us Toll-Free: 1-866-991-4700 for your free legal consultation or save time with our online claim review form below.

In a hurry? Please complete the quick contact form to the left. For a detailed case evaluation, please complete the form below and provide as much information as possible.

Free Prescription Drug Lawsuit Evaluation
First  Name:
Last Name:
Email Address:
Home Phone: - -
Cell Phone: - -
Work Phone: - - ext.
Street Address:
Address #2:
City:
State/Zip: /
What is the best way to reach you?
Please provide the best place, time and method for contacting you.
What prescription medication are you inquiring about?
Other:
How long was the medication taken?
 
When did you start taking the prescription?
 
When did you stop taking the prescription?
Your date of birth:
Please list any medical conditions you had prior to taking the medication:
Please tell us why the medication was prescribed:
Have you suffered any serious medical side effects since taking this medication? Yes No
Please describe your side effects:
Have you suffered any cardiovascular problems? Yes No
Were you taking any additional medications? Yes No
If so, please list other medications:
How did you hear about us?
I understand that by submitting this form I am not retaining a lawyer.
Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal "retainer agreement."


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— Kevin

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