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Trasylol 60 Minutes

 

 
   

Stevens Johnson Syndrome

Complete and submit the following information. Fields with (*) are required.

If you prefer, you may contact us at: (817) 334-0762 or toll free at (800) 803-3784.

This information will be kept private and confidential and used for the sole purpose of evaluating your case.

Please note that without a phone number or e-mail address, we will not be able to contact you.

You will be contacted by an attorney or paralegal, who is experienced in the area of drug injury law.

Submitting this form does not create an attorney-client relationship: Agree     Disagree
*Full Name of person needing assistance.
 *E-Mail
*Home phone
 Work phone
Cell phone
 Address
City, State, Zip
 Name of Medicine, Drug, or Over the
Counter medicine
What is best way to reach you?
(e-mail, phone, letter)
 *Injured in City, State
*Describe
*List all medication
*Please enter the digits displayed here:

For Parents or Guardians

If the person in need of assistance is a minor or is a disabled adult with an appointed guardian we will need to communicate with that parent or guardian.