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Tell Us Who You Are and How We Can Contact You.
First Name
Last Name
Number, Street & Apt.
City
State
Zip
email
Day Phone
Provide a brief personal background of the person needing assistance.
Many times we are contacted by someone other than the person in need of help, such as a parent on behalf of a child, or wife on behalf of her husband. Please provide the following information on behalf of the person who needs assistance.
The following information is for myself? Yes No
If "No" my relationship to the following person is:

Date of Birth

What medications were prescribed?
Was Pondimin or Redux taken for more than 61 days? Yes No
Name of Physician that prescribed the medication(s)
Have any of the following forms been filed for AHP settlement:
Orange
Yes No
Green
Yes No
Blue
Yes No
Pink
Yes No
Medication Start Date:
Medication Finish Date:
Diagnosed with primary pulmonary hypertension (PPH)? Yes No
Have any of the following Aortic Valve conditions been diagnosed?

Have any of the following Mitral Valve conditions been diagnosed?
Have any of the following Heart Conditions been diagnosed?
Atrial Fibrilation
Yes No
Pulmonary Hypertension
Yes No
Arrythmia
Yes No
Bacterial Endocarditis
Yes No
Atrial Enlargement
Yes No
Was an Echocardiogram performed? Yes No
If yes, when was the Echocardiogram performed?
What were the results of the Echocardiogram?
If the Echocardiogram was not performed, please explain why:
Do you have any of the following medical conditions?
High Blood Pressure
Yes No
Chest Pain
Yes No
Shortness of Breath
Yes No
Fainting
Yes No
Swollen Ankles
or Feet
Yes No
Lung Problems
Yes No
Neurological Problems
Yes No
Heart Problems
Yes No
Unexpected
Change in Health
Yes No
Other problems or comments

Yes No - I agree that this matter may be referred to an attorney in my area who may contact me.

Yes No - I agree that by submitting this form, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this form. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

 

FAULKNER LAW FIRM = 118 East Randolph = Enid, OK 73701 = 580.237.5555

 

FAULKNER LAW FIRM = 118 East Randolph = Enid, Oklahoma 73701 = 580.237.5555