Denture Cream - Zinc Poisoning Evaluation Form


We are now accepting cases in your area. If you think you have been affected by Super Poligrip Original, Ultra Fresh and Extra Care formulas that contained zinc. 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


*Injured Party's Name: __________________________________

Deceased: Yes No

Date/Place of Death: __________________________________

Gender: Male Female

Caller's name (if not injured party): __________________________________

Caller's relationship to injured party: __________________________________

* Address: __________________________________

* Phone: __________________________________

* Email: __________________________________

* DOB: __________________________________

Brand Of Denture Cream(s) Used


Brand of denture cream(s) used:
Fixodent Poligrip/Super Poligrip Other

Approximate dates injured person used each brand of denture cream:_____________ ___________________________________________________________

How long does a tube/container of denture cream normally last:_________________ ___________________________________________________________

When and why did you get dentures:_____________________________________ ___________________________________________________________

Has the injured person been diagnosed with diabetes? Yes No

Has the injured person been diagnosed with neuropathy? Yes No

Has the injured person ever had a blood test for zinc and copper levels?
Yes No

If yes, why:____________________________________________________________ ___________________________________________________________

Has the injured person ever been diagnosed with a blood disorder? Yes No

If yes, did the injured person undergo chemotherapy treatments? Yes No

If yes, when were the treatments, in relation to the use of the denture cream? ____________________________________________________________________ ___________________________________________________________

Has the injured person had any of the following symptoms:

Nausea Yes No
Vomiting Yes No
Abdominal pain Yes No
Diarrhea Yes No
Low blood pressure Yes No
Urine retention Yes No
Jaundice Yes No
Seizures Yes No
Joint Pain Yes No
Fever Yes No
Coughing Yes No
Metallic taste in mouth Yes No
Dizziness Yes No
Headaches Yes No
Blurred vision Yes No
Short-term memory problems Yes No
Numbness or tingling in feet, legs, hands, and/or arms Yes No
Unexplained pain in feet, legs, hands, and/or arms Yes No
Tendency to stumble or fall Yes No

What is the injured person's medical insurance? ______________________________ ___________________________________________________________

Does the injured person have a good relationship with their doctor? ___________________________________________________________

Has the injured person ever undergone weight loss treatment? Yes No

If yes, what kind and when? ______________________________________ ___________________________________________________________

Is the injured person a smoker? Yes No

Does the injured person have any children? Yes No

If yes, were they using denture cream while pregnant? Yes No

Do their children have any birth defects/medical issues? Yes No

Comments: ___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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”