Pharmaceutical Liability Information Center

Pharmaceutical Liability Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

What kind of medication injured you?
Choose Oneprescription medicationover-the-counter medicationvaccinedietary supplementherbal remedy

What was the medication?

Why were you taking the medication?

Briefly describe the bad reaction or injury that occurred when you took the medication

If the medication did not require a prescription, where did you buy it?

If you had a prescription, who prescribed the medicine to you?

What pharmacy filled the prescription?

When did you first start taking the medication?

When did you first notice the bad reaction or injury?

When did you stop taking the medication?

When did you learn that the medication caused the bad reaction or injury?

How did you learn about the connection between the medication and your bad reaction or injury?

Was the medication one of the following?

What other medications were you taking at the time you were injured? Include substances such as aspirin, vitamins, antacids, cold remedies, and herbal substances)

How did you out about find us?

If somebody referred you to us, who was it?

Special concerns:

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