*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 Tequin? 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 Tequin side effect:

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

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

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

8. What dosage of Tequin was prescribed? *Tequin is available in oral tablet form, as well as liquid form suitable for IV use.

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: