*Your Name:

*E-mail:

Street Address:

City:

State:

Zip:

*Phone Number:

Best time to call: DayNight

Case Facts

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

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

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 his or her relationship to you? MeSomeone Else
Relationship:

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

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

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

7. Has a lawsuit been filed concerning the Ortho Evra patch side effect: YesNo

8. At the time of the injury, was the person wearing the Ortho Evra patch: YesNo

9. If not worn at the time of injury, when was the last time the Ortho Evra patch was used 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: