Free Case Evaluation

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* First Name:
* Last Name:
Address:
Address 2:
City:
State:
ZIP:
Telephone: () -
* E-mail Address:
 
If you are inquiring on behalf of another person, please give their name and answer the following questions on their behalf:
Name of person:
Date of Birth / /
* Have you suffered a stroke you think might be linked to your use of a product containing PPA? Yes No
What kind of stroke did you have? Ischemic Hemorrhagic
When did the stroke occur? /
At the time of the stroke, what product(s) were you using that contained PPA?
1.
2.
3.
 
How long had you been using them? 1.
2.
3.
Do you have any proof you were taking these products? I had a prescription
I still have left-over, unused product
I have a store receipt
My doctor was aware I was taking the product
My friends were aware I was taking the product
Other proof
Not at this time
Would you like to make any other comments about your case?
 

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