Free Case Evaluation

Evaluation For:

Avandia

Meridia

Full Name:
Address:
Date of Birth: Social Security Number:
Cell Number: Home Number:
Spouse Name and Phone Number:
Other Next of Kin- Name & Number:
Name of Health Insurance Carrier
(or Medicaid or Medicare):

(Provide copy of insurance or Medicaid/Medicare Card)

DEATH CASES:

Name of Patient: Date of Death:
Representative Capacity:
Dates You (or Patient) Took The Drug:
Prescribing Doctor and Location of Clinic:
Name of Pharmacy and Location:
Hospital Name and Location:
Dates of Hospitalizations:
Surgery: Y/N Yes No
If yes, Type of Surgery and Date:
Name and Location of Cardiologist:
Any other Treating Doctor and Location of Clinic:
Symptoms/Injuries:

1. Heart Attack, if so, date and name of hospital:

2. Stroke, if so, date and name of hospital:

3. Congestive Heart Failure, if so, date and name of hospital or clinic:

4. Coronary Artery Disease, if so, date and name of hospital or clinic:

5. Abnormal Heart Test ( EKG, ECG, Heart Catherization), if so, date and name of hospital or clinic:

6. Death from one of the above, if so, provide death certificate, date and name of hospital or clinic:

Form Of Proof:
Long Form Intake:
Reference:
Notes:

Enter the Verification Code:

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