Chantix Case Inquiry Form

* denotes required fields
Personal Information
* Name
* Address
City
State
Zip Code
Daytime Phone Number
Evening Phone
Mobile Phone
* E-mail Address
   
Case Information
Date of Birth of Injured Person
 
Date you began using Chantix
 
Date you stopped taking the Chantix
 
What Dosage were you taking daily
 
Have you had any of the following conditions you believe are related to your taking Chantix
 
changes in behavior
agitation
depressed mood
suicidal ideation, and attempted and completed suicide
Please describe any additional symptoms you experienced
 
Additional info
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.