Vioxx ® Injury Lawyers 1.800.838.0800 Burke & Eisner Attorneys Nationwide

First we need to know a little bit about you:
Name of Injured Person
Your Name. (If not the same)
Relationship to Injured Person
Age of Injured person
Daytime Phone Number
Night Phone Number
Address
Address
City
State
Zip
To help determine if you have a claim, we need to know some basic information about your history with Vioxx^®.
When did you start taking Vioxx^®?
When did you stop taking Vioxx^®?
Have you been diagnosed with a heart attack?	Yes No
If yes, date of heart attack diagnosis:
Have you been diagnosed with a stroke?	Yes No
If yes, date of stroke diagnosis:
Have you been diagnosed with blood clots?	Yes No
If yes, date of blood clot diagnosis:
Did you develop any other heart problems while on Vioxx^®?	Yes No
If Yes, then please describe.
Please provide a description of your case and any other information you think we need to know.
Please provide your e-mail address. This is required so that we can respond to your inquiry. If you do not provide this then you may not receive a response, unless of course you have provided your phone number above.

We use your "Instant Answer" information solely to make a preliminary decision about whether you might have a claim and whether we might be able to help you. In reviewing your information we are NOT agreeing to represent you or take your case.