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Ionamin (heart and lung problems)
Please complete this claim form to request a free case evaluation from a lawyer listed on BigClassAction.com.
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Defendant:
(who caused the harm?)
Ionamin (heart and lung problems)
*
Describe your complaint:
(briefly describe the damages you have suffered)
Date of Intake:
Source of referral:
Client Name:
Date of Birth:
Social Security No.:
Please list the date(s) and for how long this drug was taken:
Have you ever had an echocardiogram?
Yes
No
What were the results of the echocardiogram?
Do you have any echocardiogram report/test results?
Yes
No
Have you ever been told you have something wrong with your heart or lungs?
Yes
No
If so, what?
Has any doctor ever informed you of a heart problem/condition related to Ionamin?
Yes
No
Name of prescribing doctor/clinician:
Name(s) of pharmacy(ies) where you obtained Ionamin? Note: If given directly by doctor or clinic, please provide name and address for doctor or clinic.
Do you have any Ionamin still in your possession?
Yes
No
Do you have prescription records for the Ionamin?
Yes
No
Have you previously filled out any forms (registered) for National Class Action Settlement Program?
Yes
No
If yes, what forms (e.g. Blue, Pink, Orange):
What is the best way for one of our attorneys to contact you to further discuss your potential case?
Do you have a copy of your medical records?
Yes
No
Can you get a copy of your medical records?
Yes
No
*
First name:
*
Last name:
*
Email address:
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Confirm email address:
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Phone number(s):
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Zip/Postal Code:
Best time & way to contact you:
I would like to be interviewed by a journalist.
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