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Vioxx Contact Form

If you believe that you or someone close to you may have a personal injury claim related to the Vioxx market withdrawal, please fill out the following questionnaire. By submitting the information below, you will enable the attorneys at the Saunders & Walker, P.A. to evaluate your case based on its merits. Please be as complete as possible in the information you provide.

If you would like to contact Saunders & Walker, P.A. for reasons other than a possible personal injury claim, please send an e-mail to .

There is no charge for this evaluation

General Contact Information

Full Name:

Street Address:

Street Address 2:

City:

State:

 E-mail Address:

Phone Number:

Work Number:

Fax Number:

Zip:

What method would you prefer we use to contact you?
What time of day would you like us to call?

If you are inquiring on behalf of another person, please give their name and answer the following questions on their behalf:

Vioxx Injury Questionnaire

Sex   Male Female
Name of person:
Birthdate:
Relationship to you:

Marital Status:    Single   Married   Divorced   Widowed

What was the dosage of Vioxx?    12.5 mg.  25 mg.  50 mg.  Other

What frequency was Vioxx taken?    Once Daily  Twice Daily  More than twice daily 

How Consistently?    Continuous  Intermittent 

Why were you taking Vioxx?
 Osteoarthritis
 Rheumatoid Arthritis
 Pain
 Migraine Headaches
 Painful Menstruation
 Other

What injury did you experience while taking Vioxx?
 Heart Attack
 Cardiac Arrest
 Stroke
 Other

Were you hospitalized for your injury?    Yes  No 

When did your injury occur (date)? 

Were you taking Vioxx at the time of the injury?  Yes  No

What was your age at the time of your injury? 

How Long had you been taking Vioxx before your injury? 

Do you have the any of the following risk factors?:
 High Blood Pressure
 High Cholesterol
 Diabetes Type I or Type II
 Overweight
 Smoking
 Angina Before Vioxx Use
 Heart Attack Before Vioxx Use
 Other Heart Condition Before Vioxx Use
 Stroke Or Mini-Stroke Before Vioxx Use
 Birth Control Pills Before Vioxx Use
 Carotid Or Peripheral Artery Disease
 No Risk Factors

If you suffered a heart attack, how are your activities now limited?:
 No limitation
 Slight limitation, comfortable with mild exertion
 Marked limitation, only comfortable at rest
 Severe limitation, confined to bed or chair

If you suffered a stroke, do you now need assistance with activities of daily living,
such as dining, dressing, bathing, shopping, transportation, working?:
 Independent, no assistance
 Mostly independent, little assistance
 Moderate assistance
 Mostly dependant, unable to live alone safely
 Dependant, full time care

Any additional comments?

Important Legal Disclaimers

Yes No - 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.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement.

By Clicking the appropriate box below, I agree to:
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