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Cuming Gillespie -> Practice Areas -> Class Action -> Pharmaceuticals -> Fosamax® -> Fosamax® Contact Form
Fosamax® Contact Form
Fosamax®:  
Name:
Address:
Phone: ( ) -
E-mail Address:
Preferred Method of Contact:
Date of Birth: year: month: day:
How did you hear about the Fosamax® Claim?
Year(s)/Date(s): on Fosamax®
Injury/Illness:        
When Diagnosed:  
When advised it could be Fosamax®-related?
What medications do you take?
Physician(s) Visited:
General Practitioner:
Hospital(Treatment of Injury):
Specialist(Treatment of Injury):
Additional Questions or Comments: