Zyprexa Information and Legal Guide
Free Case Review

1-866-972-1500
Contact Information
Fill out the following form or call 1-866-972-1500 24 hours a day, 7 days a week for a Free Case Review.

* denotes a required field (only one phone number is required).
First Name*
Last Name
Home Phone* - -
Work Phone* - -
Cell Phone* - -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip
 
Injured Person's Contact Information
The injured person is
First Name:
Last Name:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
Email Address:
Street Address:
City:
State/Zip
Date of Birth
Sex Male  Female
 
When did the person start taking Zyprexa?
 
What was the age the person started taking zyprexa?  
 
Is their proof of taking Zyprexa from:
 
Records from doctor?
Yes
No
Pharmacy records?
Yes
No
Prescription bottle?
Yes
No
 
Why was Zyprexa taken?
 
If “other” please indicate reason for taking Zyprexa:
 
Is Zyprexa still being taken?
Yes
No
 
While taking Zyprexa was person diagnosed with any of the following?
(Select Yes or No)
 
DiabetesYes  No
Diabetes mellitusYes  No
Diabetes ketoacidosisYes  No
Diabetic comaYes  No
Diabetic hyperosmolar syndromeYes  No
Death – attributed to diabetic ketoacidosisYes  No
HyperglycemiaYes  No
PancreatitisYes  No
 
If diagnosed with Diabetes, does person require insulin?
Yes
No
 
How is insulin taken:
 
Was person diagnosed with diabetes prior to taking Zyprexa?
Yes
No
If yes, has diabetes gotten worse since taking Zyprexa?
Yes
No
Does diabetes run in the family?
Yes
No
 
Additional Comments or Questions:

 
a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.
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Steigerwalt & Associates
Steigerwalt & Associates