If you or a loved one took VIOXX^® and would like to obtain a free, confidential consultation concerning your legal rights, please answer the questions below.

Your Name:

Your E-mail Address:

Your Phone Number: (formatted like: 213-555-1212)

Your state of residence: AL AK AZ AR CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Were you or a loved one injured by VIOXX^®?
[Me]           [Loved One]

Inured person's name:

Your relationship to the loved one listed above:
Friend Spouse Son Daughter Parent Sibling Other

Type of Injury:
(To select multiple injuries, hold the control button down and click on the injury)
Heart Attack Hemorrhagic Stroke Ischemic Stroke Stroke Seizure Kidney Failure Gastrointestinal Bleed Deep Vein Thrombosis Death Other

Year of Injury:
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

How long did you or your loved one take VIOXX^®?
Less than 3 months 3-6 Months 6-9 Months 9-12 Months 12-15 Months 15-18 Months 18-24 Months 2-3 Years 3-4 Years More Than 4 Years

What was the highest dosage (per day) of VIOXX^® that you took?
12.5 mg 25 mg 50 mg 100 mg

Briefly describe the circumstances surrounding you or your loved one’s injury from VIOXX^®:

Other information you would like us to have concerning your potential case:

I agree that submitting this form does NOT
create an attorney-client relationship.             I agree.