Medication, Drugs, Medical Devices Consultation

What is the name of the product, device or drug? *

Please provide the name of the device used or the drug or medication that was used or ingested.
What symptoms or injuries resulted? *
Breathing Problem / Asthma Attack Dizzyness / Vertigo Nausea Headache / Migraine / Other Pain Burn Scar or Multiple Scars Bronchitis / Lung Infection Heart Attack Stroke Paralysis Loss of Limb / Extremity Memory Loss Neurological Problem Pyschological Problem (depression, etc.) Death Other
Please list all the symptoms that resulted after use of the device or ingestion / application of the drug or medication.
Approximately what date did this matter first occur? * / MM / DD YYYY

When did you start using the product, drug or medication?
How long was the exposure to or use of the product or drug? *

How long was the period of expsoure to the product, drug or medication?
Has the affected person received treatment? *

Has the person suffering the injury or problem received treatment of any kind?
Was any time or wages lost from work as a result? *

Did the injury suffered result in lost time or lost wages for work?
Apart from medical bills paid by your insurance, was there an offer for a payment made by an insurance company? *

Other than medical bills that were or are to be paid by your insurance, has an insurance company made an offer of settlement?
This inquiry is on behalf of whom? *

Who is this inquiry for?
What is the approximate age of the person involved? *

What is the age of the person who has suffered the injury or problem?
Your state or where issue arose *

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Description of the case or services you need *

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Medication, Drugs, Medical Devices Consultation

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