*Your Name:

*E-mail:

Street Address:

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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 YAZ / Yasmin / Ocella / Gianvi? YesNo

If Yes, which pill was taken? YAZ Yasmin Ocella Gianvi

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)
Pulmonary Embolism (PE: blood clot in lung)
Deep Vein Thrombosis (DVT: blood clot in leg)
Gallbladder Removal (cholecystectomy)
Gallbladder Disease / Injury (cholecystitis)
Kidney Failure or Renal Failure
Pancreatitis

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 YAZ / Yasmin / Ocella / Gianvi side effect:

5. If there was a death from YAZ / Yasmin / Ocella / Gianvi, on what date did it occur:

6. What is the date of birth of the person who had an adverse reaction to YAZ / Yasmin / Ocella / Gianvi:

7. Has a lawsuit been filed concerning the YAZ / Yasmin / Ocella / Gianvi side effect: YesNo

8. At the time of the injury, was the person taking YAZ / Yasmin / Ocella / Gianvi: YesNo

9. If not taken at the time of injury, when was the last time YAZ / Yasmin / Ocella / Gianvi 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: