CONFIDENTIAL QUESTIONNAIRE FOR VIOXX USERS

Your Information

First Name - MI
Last Name
Street Address
City
State / Zip Code	/
DayTime Phone	- -
Evening Phone	- -
E-Mail Address
Social Security No.
Date of Birth

Your Vioxx Claim Information

Date you started taking Vioxx

Date you stopped taking Vioxx

Listed below are certain medical diagnoses that have been found that may be caused by Vioxx. Please indicate If your physician has made an actual determination that you had or have any of these conditions. Please check all that apply.

Heart Attack	Stroke
Stroke	Unstable Angina
Cardiac Thrombus	Myocardial Infarction
Respiratory Failure	Cardiac Arrhythmia
Intravascular Coagulation

Your Comments

Submit

BY SUBMITTING THIS FORM WE ARE NOT AGREEING TO ACT AS YOUR LAWYER IN ANY WAY OR AGREEING TO ATTEMPT TO RECOVER ANY DAMAGES YOU MAY HAVE SUSTAINED. IF AFTER OUR INITIAL REVIEW WE MAKE A PRELIMINARY DETERMINATION THAT YOU MAY BE ABLE TO RECOVER ANY DAMAGES WE WILL CONTACT YOU DIRECTLY AND ENTER INTO AN AGREEMENT FOR ANY SUBSEQUENT SERVICES.

Climaco, Lefkowitz, Peca, Wilcox & Garofoli, Co., LPA is committed to clients & community

Call Us Now

(877) 621-1228

Firm Contact Info

55 Public Square

Suite 1950

Cleveland, Ohio 44113

Toll Free: (877) 621-1228

Phone: (216) 621-8484

Fax: (216) 771-1632