*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 Permax or Dostinex? 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 Permax or Dostinex side effect:

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

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

7. Has a lawsuit been filed concerning a Permax or Dostinex side effect: YesNo

8. Which drug is at issue for this evaluation, Permax or Dostinex? PermaxDostinex

9. What dosage of of Permax or Dostinex was prescribed?

Click to see a photo of Permax and Dostinex pills

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: