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Case Evaluation

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Title

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State

Zip Code

Please provide the best method and times to contact you:

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

Name of drug:

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

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

Please describe any side effects:

Other Info:

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

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

please do not fill out the field below.

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