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Cuming Gillespie -> Practice Areas -> Class Action -> Pharmaceuticals -> Seroquel -> Seroquel Contact Form
Seroquel Contact Form
Salutation:  
Name:
Address:
Phone: ( ) -
E-mail Address:
Preferred Method of Contact:
Date of Birth: year: month: day:
How did you hear about the Seroquel Claim?
Year(s)/Date(s):  on Seroquel
Injury/Illness:        
When Diagnosed:  
When advised it could be Seroquel-related?
What medications do you take?
What was your weight prior to ingesting Seroquel?
What has been your maximum weight?
What is your current weight?
Physician(s) Visited:
General Practitioner:
Psychiatrist:              
Hospital(Treatment of Injury):
Specialist(Treatment of Injury):
Additional Questions or Comments: