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 Zithromax and developed
Stevens Johnson Syndrome or experienced adverse effects you
believe may be related to Zithromax:
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
Have someone contact me
| Drug | |
| Your Name | |
| Phone Number (Day) | |
| (Evening) | |
Do you or a loved one take Zithromax | Yes No |
State where incident took place |
|
Do you or they have SJS? | Yes No |
| Address |
Briefly Describe Your Concern.