Oxycontin Submission

To have a lawyer review your concern fill out the information and write a brief description of your oxycontin related injury in the form below. This information will be kept private and confidential and used for the sole purpose of evaluating your case. Please note that without a phone number or e-mail address we will not be able to contact you.

Title:

First Name:

  M. I.

  

 Last Name:

 Address:

 City:

 State:

 Zip Code:

 Phone Number (day):

 Phone Number (eve):

Email Address 

 If this inquiry is not for yourself, please tell us the name of the person?:

Title:

First Name:

M. I.

Last Name:

What is the Injured's relationship to you?:

 Injured's Date of Birth?
(ie mm/dd/19yy)  

 Have you or they taken Oxycontin?:

 Yes No

 How long was the medication taken?:

 Are you still taking Oxycontin?:

  Yes No
Do you have proof of taking these medications from: 

 Prescription Bottle:

  Yes No

 Pharmacy Records:

  Yes No

 Record from Doctor:

  Yes No

Did you experience withdrawal symptoms or adverse side effects?: 

  Yes No

 What were the side effects?:

 Did you attempt to stop taking Oxycontin?

 Yes No

Have you or a loved one particpated in a drug rehabilitation program?

Please briefly describe your legal concern
 
 I understand that submitting this form does not create an attorney client relationship: Agree


Submit by pressing button below