( * indicates required field)
1. What state and county is your legal issue in?*
STATE: New York
3. How will you pay for legal services if you decide to hire a lawyer?
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(check all that apply)
4. Approximately when did you take the drug that caused the injury or side effects?
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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.
*