Online Lawyer Source

*Name:

Address:

Telephone

*Email Address

Date of Birth

Date started and stopped celebrex

Dosage

Heart attack?
Yes
No

The State Your Drug Was Prescribed In

The Date You Started Taking the Drug

Date You Stopped Taking the Drug

Dosage of Baycol You Were Prescribed

Have You Experienced the Following?

Rhabdomyolysis
Yes
No

Muscular Pain or Complaints
Yes
No

Kidney Failure of Other Kidney Complications
Yes
No

Elevated CK or Elevated CPK
Yes
No

Were you Hospitalized While Taking Baycol?
Yes
No

Were Any Tests Taken While you Were on Baycol?
Yes
No

Describe Tests and Results

Do You Currently Have an Attorney Who Represents You on Your Baycol Claim?
Yes
No

Attorney's Name

Address

City

State

Zip