Parker, Waichman, Alonso LLP

Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

What additional medications were you taking at the time?

Was Gemfibrozil (Lopid) taken while taking Baycol?
Yes
No

Has Rhabdomyolysis been diagnosed?
Yes
No

Have any of the following side effects occurred?
Muscle Pain
Liver Problems
Kidney Problems
General Weakness
Dark Urination
Malaise
Nausea
Death

Please further describe side effects:

Other Info:

No Yes, I agree to the Parker Waichman Alonso LLP disclaimers.Click here to review all.

Yes, I would like to receive the Parker Waichman Alonso LLP monthly newsletter, InjuryAlert.