Free Case Evaluation

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Title
First Name*
Last Name*
Email Address*
Phone*
Other Phone
Address
City
State
Zip
What is your age?
Did you use Yaz or Yasmin?
Yes No

Did you suffer any of the following conditions? Yes No Don't Know
· Death · Blood Clots · Heart issues · Deep Vein Thombosis (DVT) · Pulmonary Emboli · Gallbladder Disease · Strokes ·

Have you received medical treatment??
Yes No
Have you contacted another attorney regarding your case?
Yes No
Questions and Comments:*
I understand that submitting this form does NOT create
an attorney client relationship: AGREE