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This information will be kept private & confidential & used for the sole

purpose of evaluating your case. 
 

Please note that without a phone number or e-mail address, we will not

be able to contact you.

If you or a family member have taken a drug and developed Stevens

Johnson Syndrome or experienced adverse effects you believe may be

related to the drug:

Please fill out the information and write an informal case description

in the form below. 
 

You will be contacted by an attorney or paralegal, who is experienced

in the area of drug injury law.

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* Submitting this form does not create an attorney-client relationship:

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Drug

Other Bextra AravaCelebrexClinoril DayproEnbrelFeldene Motrin \ Advil Remicade NaprosynVioxx Zithromax

*Your Name

*Phone Number (Day)

*(Eve.)

*E-mail

Do you or a loved one take a drug?

Yes   No

*State where incident took place

Do you or they have SJS?

Yes   No

Address

*Please enter this verification code:

Briefly Describe Your Complaint about the drug.