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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?
Yes No
Please describe your legal issues and needs.

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