Allen Law Firm
 

Ortho Evra Case Evaluation Form

The initial consultation is free of charge, and if we agree to accept your case, we will work on a contingent fee basis, which means we get paid for our services only if there is a monetary award or recovery of funds.   Note: Required fields are marked with an asterisk ( * ).

First Name: * 
Last Name: * 
E-mail: * 
Phone:  
Address: * 
City: * 
State: * 
ZIP: * 
Date you began using Ortho Evra (mm/dd/yyyy)
Date you stopped using Ortho Evra (mm/dd/yyyy)
Have you suffered any of the following?  
Where did you
hear about us?
 
Other information:




 

 

Allen Law Firm
3838 Oak Lawn Ave., Suite 1100  |  Dallas, Texas 75219
phone
(214) 521-2300 | toll free (888) 345-LAW1 | fax (214) 528-7755



©2008-2010 Allen Law Firm
All rights reserved


Legal Disclaimer | Privacy & Legal Statement

Web Design by Epoch Online