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Vioxx / Bextra Intake

If you or a love one have suffered heart attack or stroke. or if a loved one has died while taking Vioxx / Bextra, please fill out the form below.

Describe the nature of your complaint in one short sentence


Briefly describe the damages you have suffered


Have you or a loved one experienced Myocardial infraction?
Yes
No

Have you or a loved on experienced Unstable angina?
Yes
No

Have you or a loved one experienced Cardiac thrombus?
Yes
No

Have you or a loved one experienced Resuscitated cardiac arrest?
Yes
No

Has a loved one experienced sudden or unexplained death?
Yes
No

Have you or a loved one experienced Ischemic stroke?
Yes
No

Have you or a loved one experienced Transient ischemic attacks?
Yes
No

Please state your inquiry


Date of Birth (mm dd yy)


Date of incident


How long have you used Vioxx?


Do you have a copy of your medical records?
Yes
No

Can you get a copy of your medical records?
Yes
No

Have you or a loved one taken Vioxx?
Yes
No

Perscribed by what doctor?


Dosage:


Your Full Name


Your Email Address


Your Home phone


Address (City, State, Zip)


Pleasegive smoking history if any:


Height and Weight:


Past medical history:


Family history:


Please list if you have any of the following: Diabetes (type, how long)? Stroke? High BP-any meds? High Cholersterol-any meds? Pacemaker? Prior Heart Attack? Cardiac Sx(stents,bypass,angioplasty)? Vascular disorders/Phlebitis(leg clots)?


Any other Health Problems?


Other medications on at same time with vioxx:


Warnings: Did anyone tell you of any warnings/side effects? Verbally or in writing?


Did anyone tell you your heart attack/stroke was related to Vioxx use?




Sending this message does not create an attorney-client relationship, which can be done only after personal consultation and with a written retainer agreement.
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