Fosamax Lawsuits - Ask our Lawyers if You Qualify for a Claim Against Merck
PERSONAL INFORMATION
Title:
First Name:
Last Name:
E-mail Address:
Address:
City:
State:
Zipcode:
Phone:
() - ext.
Date of Birth:
Bisphosphonate Medication Information
Which city and state was drug prescribed in?
City:
State:
Do you have proof of taking the drug from a prescription record, pharmacy record or record from a doctor?
Yes
No
Please check all that apply to you.
Fosamax
Actonel
Didronel
Skelid
Zometa
Aredia
Boniva
What were the dates of use?
Start Date
End Date
Describe why bisphosphonate was prescribed?
Please check all that apply to you.
Cancer
Osteoperosis
Osteopenia
Hypercalcemia
Other
Please describe
DENTAL PROCEDURES
Were dental procedures (e.g. tooth extractions, caps, bridge work, etc.) preformed at any time after you began taking the bisphosphonate? (please describe. Please provide dates of each dental procedure.)
If yes, when were the conditions requiring a dental procedure first identified?
OSTEONECROSIS INFORMATION
Since taking bisphosphonate have you been diagnosed with osteonecrosis of the jaw?
Yes
No
If yes, what was the date of diagnosis?
Since taking bisphosphonate have you been diagnosed with any other dental or jaw conditions?
Yes
No
If yes, which condition have you been diagnosed with?
What was the date of diagnosis?
Has any doctor linked your jaw/dental problems to this drug?
Yes
No
COMMENTS
Do you currently have an attorney assisting you with this matter?