Accutane injury evaluation form :: accutane injury lawyers

Date Today (mm/dd/yyyy)

Full Legal Name

Home Mailing Address

City – State – Zip

Email

Home Telephone

Work Telephone

Cell Phone

Birthdate (mm/dd/yyyy)

I am

Male

Female

Dates Accutane was used (mm/dd/yyyy):
1. Start

End

2. Start

End

3. Start

End

Where did you take Accutane? (City / State)

What have you been diagnosed with (what is your injury from taking Accutane)? In other words, what injury/condition did you develop as a result of taking Accutane? In order to possibly pursue a claim against the manufacturer of Accutane you must have been diagnosed with an injury or condition.

When were you diagnosed with the injury/condition? (Be specific)
(Date / Year)

Is there a family history of the diagnosed problem(s):

Yes

No

If yes, who (mother, grandmother, etc.)

How much time elapsed between the last time you took Accutane and when you first noticed the symptoms of or were diagnosed with IBD?

WHEN did you realize that Accutane caused your disease and/or condition(s)? (Example: Doctor told you, TV, Newspaper, etc.)

HOW did you realize that Accutane caused your disease and/or condition(s)? BE SPECIFIC: (Most of our clients did not know until after they saw a news article or saw an advertisement. For Statute of Limitations Issues, this is Very Important)

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