1.  Did you or the person you are calling about have any of the following diagnosed by a doctor within 24 hours of taking Vioxx?

Heart Attack                Date:

Stroke                        Date:

Pulmonary Embolism  (blood clot in lungs)     Date:

None of the Above (including chest pains, bypass surgery, congestive heart failure, mini-strokes, or TIA's, etc...)

If you have not had a doctor say you have had a heart attack, stroke, or pulmonary embolism, you may have a case, but you do not meet our criteria and you will need to contact a different lawyer.  Please do not provide any additional information.

2.  Are you the injured party?

Yes    Please go to question 4

No

3.  What is your relationship to the injured party?

Spouse   

Child

Sibling

Friend

Other:

4.  Did the injured party survive the stroke or heart attack?

Yes   

No    Date of Death:

5.  Approximately how long was Vioxx taken before the injury?

  Length of time:

6.  How did you hear about us?

    TV

    Newspaper         Name:

    Magazine           Name:

    Other -      Describe  :

Contact Information:

First Name           

Last Name           

Address 1            

Address 2            

City                        State    ZIp 

Day Phone          

Evening Phone     

Email                  

 Injured party contact information

First Name           

Last Name           

Address 1            

Address 2            

City                        State    Zip 

Day Phone          

Evening Phone     

Email                  

Date of Birth