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Avandia Intake Form

NOTE: An asterisk (*) indicates REQUIRED information. The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

Were you taking Avandia for Type II Diabetes?
Yes  No 

*Name:

Address:

City:

State:

Zip:

Telephone no:

Cell phone no:

*E-mail address:

Date of Birth:

Did you suffer any of the following injuries?

Heart Attack
Yes  No 

Ischemic Stroke
Yes  No 

Congestive Heart Failure
Yes  No 

Macular Edema
Yes  No 

Liver Failure
Yes  No 

Broken Bones/Fractures in hand or feet
Yes  No 

Other, please specify:
Yes  No 

Age at time of injury:

Did the injury occur while taking Avandia?
Yes  No 

Our Location

MURRAY, FRANK & SAILER LLP
275 Madison Avenue, Suite 801
New York, NY 10016
Phone: (212) 682-1818
Toll-Free: (800) 497-8076
Fax: (212) 682-1892
E-Mail
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