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Please fill out the form below to have your case evaluated. Provide as much information as possible to speed the processing of your inquiry.

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Title
* First Name
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Additional contact information: Use this area to add country codes, foreign addresses, special instructions, etc.

Injured Person Information
Date of Birth	(mm/dd/yyyy)
Whom are you inquiring on behalf of?
If you are NOT inquiring on your own behalf, what is your relationship?
Is the person deceased?	Yes No
If deceased, the cause of death as stated on the death certificate:
Date of Death	(mm/dd/yyyy)
Case Information
During what period of time was Vioxx® taken?	(Start) (End)
Why was Vioxx® perscribed?

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

List names/addresses of any doctors who prescribed Vioxx®:

Did effects from Vioxx include:

Dates medical problem(s) first occurred:

Other Information:

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