Tapón para los oídos 3M

Potential clients (injured person) name
DOB*
Inquirer Name (if different)
Inquirer’s relationship to injured person
Mailing Address
Physical Address (if different)
City/State/Zip
Primary phone
Secondary phone
Email Address
Injured Person spouse name
(If Injured Person Is Deceased)
Date of Death
State of Death
State of Ingestion
Cause(s) of Death
Residency at time of Death: City & State
Has an Estate been opened
If yes, who has been appointed Personal Representative
When were you first prescribed Elmiron?
Are you still taking the drug?
If not, when did you stop taking the drug?
Did you stop taking the drug after you learned the link to macular degeneration?
Were you diagnosed with interstitial cystitis?
If not, what condition was the drug prescribed for?
Were you diagnosed with macular degeneration (mm/yr)?
Which state were you living in when:
The drug was prescribed?
While you were taking the medication (if more than one, list all)?
When you were diagnosed with macular degeneration (or other vision loss)?
Has a doctor told you Elmiron caused your macular degeneration?
If so, when (mm/yr)?
When did you first think your macular degeneration (or other vision loss) was caused by Elmiron (mm/yr)?
When did you first hear about potential lawsuits related to Elmiron?
Please be sure to save all evidence of Elmiron, including any proof of purchase, receipts, packaging, boxes, etc.

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Tapón para los oídos 3M

Tapón para los oídos 3M

(If Injured Person Is Deceased)

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