*Your Name:

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Street Address:

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*Phone Number:

Best time to call: DayNight

Personal Injury Case Facts

1. Have you, a family member, or some other person you know suffered a serious side effect caused by Bextra?YesNo

If yes, please indicate which condition(s) the doctor diagnosed; check all that apply:

2. What was the date of the initial diagnosis:

3. What is your date of birth:

4. Have you filed a lawsuit concerning your Bextra-related disease?YesNo

5. What dosage of Bextra was prescribed?

If you would like to see a picture of Bextra pills to identify dosage, click here

Wrongful Death Case Facts

1. Was a Bextra-related condition possibly involved with the death of a family member or someone else you know? YesNo

If yes, please indicate which condition(s) the doctor diagnosed before or at the time of death; check all that apply:

2. What was the date of the initial diagnosis:

3. Have you or someone else filed a lawsuit concerning this death?YesNo

4. What was the date of death?

5. What dosage of Bextra was prescribed, if known?

If you would like to see a picture of Bextra pills to identify dosage, click here

Is there any additional information you would like to include?

Please enter any additional information about this claim, as well as any comments or questions you may have, in the following space: