Opioid Lawsuit Qualification Form
Answer a few short questions to see if you potentially qualify for this lawsuit.
Did you or your loved one take opioids prescribed for you OR did you or your loved one take opioids prescribed for someone else?
*
Yes
No
Did you or your loved one become opiate dependent?
*
Yes
No
Did you or your loved one overdose from opioids?
*
Yes
No
Did your loved one pass away from his/her opioid addiction?
*
Yes
No
Not Applicable
Please provide us with contact information so that our legal team may contact you to discuss your potential case.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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