Free Case Evaluation

Online Fosamax Free Case Review Form

* Your Name:
	Mr. Mrs. Ms.
Marital Status:	Single Married Divorced Separated Widowed
Address:
City:
County:
State
Zip:
Home Phone:
Work Phone:
Cell Phone:
* E-mail Address:
Your Employer:
Employer Address:

Fosamax Injured Person Information:
Date of Birth:
On whose behalf are you inquiring?:
If you are NOT inquiring on your own behalf, what is your relationship?
Is the person deceased?	Yes No
If deceased, the cause of death as stated on the death certificate:
Date of Death:
Was there an autopsy performed?	Yes No

Case Information:
During what period of time was Fosamax prescribed?
	Start: End:
Why was Fosamax prescribed?
What dosage of Fosamax were you prescribed daily? (i.e. 25mg, 50mg, 75mg)
List names / addresses of any doctors who prescribed Fosamax:
Did effects from Fosamax include:
Osteonecrosis of the Jaw Yes No
Abdominal Pain Yes No
Death Yes No
Other medical problems since Fosamax usage:
Other Information:
How did you find us?
Please review your information before sending.

Please know that you are not considered a client of this firm until your case has been accepted by us and you have signed a formal retainer agreement.

The information contained in this site is provided as a public service for informational purposes only and is not intended to be a comprehensive statement of the law or, in particular, to contain legal advice. Laws vary from state to state and are subject to change, which could affect the information available on this site. If you have questions regarding any information found on this site, you should consult an attorney who can investigate the particular circumstances of your situation. Persons receiving information found on this site should not act on this information without receiving professional legal counsel. Use of and access to this web site does not create an attorney client relationship between this law firm and the user or browser. The opinions expressed at or through this site are the opinions of the individual author and may not reflect the opinions of the firm or any individual attorney.

Name:

Phone:

Email:

How did you hear about us?

Comment/Questions:

Copyright © Hardison & Associates. All rights reserved. Disclaimer.
North Carolina Fosamax Lawyers, Osteoporosis Drug Injury Attorneys, Pharmaceutical Negligence, Serious Bone Disease, Osteonecrosis of the Jaw, ONJ, Dead Jaw, Antibiotic Therapy, Surgery, Bisphosphonates, Personal Injury
Serving – North Carolina, Raleigh, Durham, Dunn, Fayetteville, Greensboro, Charlotte
Website by Consultwebs.com, Inc. – Legal webs for Personal Injury Lawyers