Free Case Evaluation

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Please fill out the form below to have your case evaluated. Provide as much information as possible to speed the processing of your inquiry

* Items are required.
There is no charge for this evaluation.

Title
* Name
* Email Address
* Home Phone     
Mobile Phone     
Work Phone     
*provide at least one phone number
Street Address
Apt/Suite
City
State
Zip
What is your age?
What is the best way to reach you? Please provide the best place, time, and method for contacting you.
Additional contact information: Use this area to add country codes, foreign addresses, special instructions, etc.
Injured Person Information
Date of Birth (mm/dd/yyyy)
Case Information
During what period of time was Accutane® taken?
 (Start)
(End)
List names/addresses of any doctors who prescribed Accutane®:
Why was Accutane® perscribed?
Were there any other medications taken with Accutane®? yes no
If yes , list other medications taken:
Did Accutane® appear to cause depression? yes no
Was suicide attempted? yes no
Did a loved one committ suicide? yes no
Was depression a problem before taking Accutane®? yes no
Was suicide attempted before taking Accutane®? yes no
Was a Psychiatrist/Psychologist ever seen before taking Accutane®? yes no
If yes, please describe treatment:

Have any of the following injuries been diagnosed after taking Accutane®?
Ulcerative Colitis yes no
Crohn's Disease yes no
Inflammatory Bowel Disease yes no
Rectal Bleeding yes no
Irritable Bowel Syndrome (IBS) yes no
Premature Closure of Growth Plates yes no
Dessicated Spinal Discs yes no
Stroke yes no
Central Nervous System Injuries yes no
Musculoskeletal Injuries yes no
Bone and Muscle yes no
Damage and Deterioration of the Spine yes no
Cardiovascular Injuries yes no
Liver Damage yes no
Hepatitis or Hepatoxicity yes no
Kidney Damage yes no
Pancreatitis yes no
Immune System Injuries and Disorders yes no
Lupus yes no
Hearing Damage yes no
Vision Damage yes no
Thyroid Disorders yes no
Multiple Sclerosis yes no
Any Other Significant Surgeries yes no
If any of the above injuries or illnesses have been diagnosed, please describe diagnosis:
When did you realize that Accutane® caused your condition? (please provide dates)
If any of the above injuries or illnesses have been diagnosed, please list date(s) of diagnosis:
If any of the above injuries or illnesses have been diagnosed, please provide name, address and phone number of Doctor who made diagnosis:
Please describe other medical problems associated with Accutane® use: