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Pharmaceutical Litigation Form

Pharmaceutical Litigation Case Form

NOTE:  An Asterisk (*) Indicates REQUIRED Information.

*Full Name:

Home Address:

City:

State:

Zip:

Phone Number:

  

*E-mail Address:
 

What is the name of the medication you took?


 

Where, when and by whom was the medication purchased?


 

Was this medication prescribed or over-the-counter?


 

Where, when and by whom was the medication prescribed (if applicable)?


 

How much/how long did you take the drug?


 

What problems resulted from taking the drug and have you received any medical care or treatment for the problems?


 
   

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The Miami, Florida, law firm of Panter, Panter & Sampedro, P.A. provides experienced legal advice and representation to injured people from throughout the state of Florida, including South Florida, the Florida Keys, Central Florida, and Northern Florida; Miami Dade, Duval, Leon, Marion, Orange, Hillsborough, Pinellas, Palm Beach, Lee, Collier, Monroe and Broward counties; and cities and communities such as Tallahassee, Jacksonville, Ocala, Orlando, Tampa, St. Petersburg, Clearwater, Fort Myers, Naples, West Palm Beach, Boca Raton, Fort Lauderdale, Hollywood, Miramar, North Miami Beach, Miami Beach, Hialeah, Coral Gables, Coconut Grove, Pinecrest, Kendall, Homestead, Key Biscayne and Weston.