VIOXX LITIGATION
1-800-510-7862
 
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Injured Person Information:
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If you are NOT inquiring on your own behalf,
what is your relationship to the injured party?
Is the person deceased? Yes No

If deceased, the cause of death
as stated on the death certificate: 

Date of Death:
Was there an autopsy performed? Yes  No  n/a
Case Information:

During what period of time was Vioxx prescribed?
Start End

Why was Vioxx prescribed?

What dosage of Vioxx were you prescribed daily? (i.e. 25mg, 50mg, 75 mg)

List names/addresses of any doctors who prescribed Vioxx:


Did effects from Vioxx include:

Heart Attack Yes No
Stroke Yes No
Blood Clots Yes No
Deep Vein Thrombosis Yes No
Pulmonary Embolism Yes No
Swelling Yes No
Heart Failure Yes No
Kidney Problems Yes No
Irregular Heart Rhythm Yes No
High Blood Pressure Yes No
Death Yes No


Other medical problems since Vioxx usage:

Other Information:

Disclaimers:
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to Pharmaceutical Litigators
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