Orthro-Evra 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 began using Patch
 
Date stopped using Patch
 
Did you experience any of the following
 
Blood Clots
Deep Vein Thrombosis (DVT)
Pulmonary Embolism
Heart Attack
Stroke
Death
Please Describe any other effects you think may be attributed to your use of the Ortho Evra Patch
 
Do you smoke cigarettes?
 
Yes
No
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.