Ortho Evra Birth Control Patch Lawyers at Anapol Schwartz | Philadelphia Pennsylvania Attorneys at Law

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PERSONAL INFORMATION

Title:

First Name: *

Last Name: *

E-mail Address: *

Address:

City:

State:

Zipcode:

Phone: * () - ext.

Date of Birth:

ORTHO EVRA LAWSUIT INFORMATION

Are you a smoker or non-smoker?

Please describe your problems from Ortho Evra:

Please indicate which condition(s) the doctor diagnosed: (check all that apply)

Blood Clot
Heart Attack
Stroke
Pulmonary Embolism (PE)
Myocardial Infaraction (MI)
Deep Vein Thrombosis (DVT)
Cerebrovascular Accidents (CVA)
Other

If you have any other injury, please describe:

Date of Diagnosis

BIRTH CONTROL INFORMATION

When did you use the Ortho Evra Birth Control Patch?

Start Date

End Date

What other types of birth control have you used in the past 3 years?

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