( * indicates required field)
1. What state and county is your legal issue in?*
3. How will you pay for legal services if you decide to hire a lawyer?*
(check all that apply)
4. Approximately when did you take the drug that caused the injury or side effects?*
6. Have you received any medical treatment as a result of the injury or side effects?
8. What is the current status of your claim?
9. Have you spoken to a lawyer regarding this matter?
11. Please provide any additional relevant information here. Do not disclose any information you wish to remain confidential.*