Avandia (Rosiglitazone) Evaluation Form


We are now accepting cases in your area. If you think you have been affected by Avandia (Rosiglitazone), Print this form. Fill it out and Fax to 520-881-0740 or mail to the address listed below for a free legal evaluation.

Questions with an asterisk (*) are required.

Client Information


* Name: __________________________________

* Address: __________________________________

* Phone: __________________________________

* Email: __________________________________

* DOB: __________________________________

Heart Attack Stroke Congestive Heart Failure

Death Cause of Death: __________________________________

Other: __________________________________

Date of Injury: __________________________________

Medication


Avandia Avandaryl Avandamet

Start Date: ___________________ Stop Date: ___________________

Dosage: ___________________

Doctors/Hospitals/Facilities


Prescribing Dr.: ___________________ Hospital: ___________________

Treating Dr.: ___________________ Hospital: ___________________

Pharmacy: ___________________

Other


Have you contacted other firms? Yes No

If yes, who?: ___________________

Are you a smoker? Yes No

The use of this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be written on this form. By signing this form, you have read and agree to our disclaimer.

Name: ___________________

Signature: ___________________ Date: ___________________

MOELLER LAW OFFICE
3433 E FORT LOWELL RD STE 105 TUCSON, AZ 85716-1791
PHONE: 520-795-8852 - TOLL FREE: 877-369-8800
“ARIZONA LAYWERS PROTECTING ARIZONANS”