Vioxx 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 started taking the Drug
 
Date you stopped taking the Drug
 
What Condition was Vioxx used to treat
 
What Dosage were you prescribed daily
 
Have you had any of the following conditions you believe are related to your taking Vioxx
 
Heart Attack
Stroke
Blood Clots
Heart Attack
Death
Other (Specify)
Please describe any further effects
 
Additional info
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.