Title Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.
* First Name
* Last Name
* Email Address
* Phone Number
Cell Phone Number
Office Phone Number
Street Address
Apartment/Suite
City
State -Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-
Zip Code
Please provide the best method and times to contact you:
Date of birth of person injured (mm-dd-yyyy):
Date you started taking the drug (mm-yyyy):
Date you stopped taking the drug (mm-yyyy):
What condition was this medication prescribed to treat?
Were any of the following health condition diagnosed while taking or after taking Premarin? Ovarian CancerLupusSclerodermaGall Bladder CancerStroke
What was the date of diagnosis?
Please describe diagnosis:
Please describe history of HRT drug prescriptions (please provide date and drug used in chronological order):
Please further describe side effects:
Other Info:
No Yes, I agree to the Parker Waichman Alonso LLP disclaimers.Click here to review all.
Yes, I would like to receive the Parker Waichman Alonso LLP monthly newsletter, InjuryAlert.