Vioxx Class Action Registration

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Name:

Address: (please include Postal Code, City/Town, and Province)


Home Phone Number

Alternative Phone Number

E-mail

Date of Birth:(mm/dd/yy)

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When did you or a loved one begin taking VIOXX?

Why was it prescribed to you or a loved one?


Have you or a loved one experienced a heart attack?

Yes     No

Have you or a loved one experienced a stroke?

Yes     No

Has a loved one died while taking VIOXX?

Yes     No

Have you or a loved one experienced any sudden or unexplained adverse effects while on VIOXX?

Yes     No

If yes, please describe:

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