*Your Name:

*E-mail:

Street Address:

City:

State:

Zip:

*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 Crestor? YesNo

If yes, please indicate which disease(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 Crestor-related disease?YesNo

5. What dosage of Crestor was prescribed?

See a picture of Crestor pills to identify dosage

6. Were you taking Lopid (gemfibrozil) at the same time you were taking Crestor?YesNo

7. Were you taking Coumadin at the same time you were taking Crestor? YesNo

Wrongful Death Case Facts

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

If yes, please indicate which disease(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 Crestor was prescribed, if known?

See a picture of Crestor pills to identify dosage

6. Was the deceased taking Lopid (gemfibrozil) at the same time he or she was taking Crestor?YesNo

7. Was the deceased taking Coumadin at the same time he or she was taking Crestor?YesNo

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: