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Street Address:

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Best time to call: DayNight

Case Facts

1. Has a doctor said that you have a medical condition caused by Meridia? YesNo

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

Stroke (Cerebrovascular Accident or CVA)
Heart Attack (Myocardial Infarction or MI)
Sudden Cardiac Death

Other adverse side effect:

2. Would the case you are describing be a personal injury case or a wrongful death case:
Wrongful DeathPersonal Injury

3. Is this for you or someone else, and if it is for someone else, what is her relationship to you? MeSomeone Else
Relationship:

4. What was the date of the initial diagnosis of the Meridia side effect:

5. If there was a death from Meridia, on what date did it occur:

6. What is the date of birth of the person who had an adverse reaction to Meridia:

7. Has a lawsuit been filed concerning the Meridia side effect: YesNo

8. At the time of the injury, was the person taking Meridia: YesNo

9. If not taken at the time of injury, when was the last time Meridia was taken prior to injury:

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: