Accutane side effects lawsuits – submit a case for legal help

Title:

First Name:

  M. I.

 

 Last Name:

 Address:

 City:

 State:

 Zip Code:

 Phone Number (day):

 Phone Number (eve):

Email Address 

 If this inquiry is not for
yourself, please tell us the name of the person?:

 Title:

 

First Name:

   MI

 

Last Name:

What is the Injured’s relationship
to you?:

Injured’s Date of Birth?
ie (mm/dd/19yy)

 Have you or they taken
Accutane?:

Yes No

Date(s) of use?
(mm/yyyy – mm/yyyy)

 What City and State Was
Accutane Prescribed in?

 Have you
been diagnosed with any of the Following:
Inflammatory
Bowel Disease (IBD)?
  YesNo
Rectal
Bleeding?
YesNo Crohn’s
Disease?
Yes No

 Ulcerative Colitis?

Yes No

 Muscle Damage?

Yes No

Heart Problems?

Yes No

 Date of Diagnosis?

 Did you take Accutane
during pregnancy?

 Yes No

 If yes, was the child
born with birth defects?

 Yes No

 Child’s date of birth?

 Did you ever need phyiatric
treatment?

 Yes No

 Did you ever attempt
suicide?

 Yes No

 If yes, date of suicide
attempt?

What other side effects have
you experienced from taking accutane?:

If you or they experienced any
other behavioral changes while on accutane, please describe them
and your legal concern:

 
 I understand that submitting this form
does not create an attorney client relationship: Agree

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