Daypro Message Board Submission Form

Information Request Form

Submit Your Inquiry to Our Attorneys for a free evaluation.

This information will be kept private and confidential and 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 Motrin \ Advil or other Ibuprofen Products and developed Stevens Johnson Syndrome or experienced adverse effects you believe may be related to Motrin \ Advil or other Ibuprofen Products:

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.

Please read and agree to our terms and conditions.

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

Agree Disagree

* Required

Have someone contact me

Drug
*Your Name
*Phone Number (Day)
*(Evening)
*E-mail
Do you or a loved one take	Yes No
State where incident took place
Do you or they have SJS?	Yes No
Address

Briefly Describe Your Concern.