Stevens Johnson Syndrome

Complete & submit the following information. If you prefer, you may contact us at
(817) 334-0762 or toll free at (800) 803-3784.
Fields with (*) are required
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:

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*Full Name of person in need of assistance.	*E-Mail
*Home	Work
Cell	Address
City, State, Zip	What is best way to reach you (e-mail, phone, letter)
Name of Medicine, Drug, or Over the Counter medicine	*Injured in City, State
*Describe
*List all medication

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.