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Fill out this brief form to find out if you have a Fosamax Lawsuit:

First Name:
Last Name:
E-mail:
Address:
City:
State:
Zipcode:
Phone:
Date of Birth:
 
Where was the drug prescribed?
 
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
Zometa
Aredia
Skelid
Boniva
When was the drug used?
Start Date:
End Date:
Describe why bisphosphonate was prescribed:
Please check all that apply to you:
Cancer
Osteoperosis
Hypercalcemia
Other
Osteopenia
Have you been diagnosed with Esophageal Cancer?
Yes No
Date of Diagnosis:
Were dental procedures preformed at any time after you began taking the bisphosphonate?
Yes No
Please describe providing dates of each dental procedure (e.g. tooth extractions, caps, bridge work, etc).

When were the conditions requiring a dental procedure first identified?
Since taking bisphosphonate have you been diagnosed with osteonecrosis of the jaw?
Yes No
What was the date of diagnosis?
Since taking bisphosphonate have you been diagnosed with any other dental or jaw conditions?
Yes No
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
Do you currently have an attorney assisting you with this matter?
Yes No
Please describe your legal issues and needs: