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Brown & Crouppen

Pharmaceutical Injury Review Form

Improperly designed, manufactured, or labeled pharmaceutical drugs can cause serious injuries or death. The attorneys at Brown & Crouppen can help you make informed decisions about your legal rights. Call us Toll-Free: 1-888-891-2022 for your free legal consultation or save time with our online claim review form below.

For a detailed case evaluation, please complete the form below and provide as much information as possible.

Free Prescription Drug Lawsuit Evaluation

First Name:*
Last Name:*
Email Address:*
Home Phone:
Cell Phone:
Work Phone:
Street Address:
Address #2:
City:
State/Zip:	/
What is the best way to reach you? Please provide the best place, time and method for contacting you.
What prescription medication are you inquiring about?	Other:
How long was the medication taken?
When did you start taking the prescription?
When did you stop taking the prescription?
Your date of birth:
Please list any medical conditions you had prior to taking the medication:
Please tell us why the medication was prescribed:
Have you suffered any serious medical side effects since taking this medication?	Yes No
Please describe your side effects:
Have you suffered any cardiovascular problems?	Yes No
Were you taking any additional medications?	Yes No
If so, please list other medications:
How did you hear about us?
* I understand that by submitting this form I am not retaining a lawyer. Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal "retainer agreement."

Copyright © 2007 - Brown & Crouppen, P.C., Attorneys at Law, All Rights Reserved.
St. Louis, Missouri - Fairview Heights, Illinois. Injury Lawyers in MO & IL.
Concentrating In Personal Injury Accidents & Disability, Including Medical Negligence, Work Related Injuries, Dangerous Drugs & Devices, Harmful Chemical Exposure, and Financial Matters - Zyprexa, Neurontin Lawyers, Prempro HRT Attorneys. Serving Crawford, Franklin, Gasconade, Iron, Jefferson, Lincoln, Pike, St. Charles, St. Francois, St. Genevieve, St. Louis, Warren, Washington Missouri & Illinois Counties.

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Past results afford no guarantee of future results. Every case is different and must be judged on its own merits.

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