Steigerwalt & Associates Case Evaluation form and Script Information
Note for phone operators: Many callers may have questions that MUST be answered by attorneys ONLY. It is important to indicate to the caller that you are simply "intake specialists" ONLY and can not offer legal advise. It is your job to simply help the caller and to fill out the online form on their behalf to provide as much information to Steigerwalt & Associates as possible in order for their attorneys to provide a free case review.

Script Part 1

Thank you for calling the case intake center for Steigerwalt [stie-ger-walt] & Associates, my name is___________________ and I am here to help you with your potential case. During the next few minutes I will be asking you various questions. This information will be sent to the law firm so that they can review it... for free. You will be contacted by phone within 4 hours by an attorney from Steigerwalt [stie-ger-walt] & Associates to discuss your potential case. Let's begin.
Introduction

Who is the injured person?

If the caller is the injured person click here

If the caller is calling on behalf of someone else continue

Contact Information
First Name*
Last Name
Home Phone* - -
Work Phone* - -
Cell Phone* - -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip
Injured Person Information
(This is information about the injured party.)
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 person start taking Zyprexa (Date)?
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 did the person suffer from any of the following:
(Please 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:

 

Script Part 2

Finally, I need to read the following and have you agree to each of these statements.
Disclaimers:
a. leaving this box checked, I agree to receive future advertisements and announcements from our firm its affiliates and partners.
b. 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.
d. 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.