Accutane Birth Deffects Lawsuits: If you or a loved one has taken Accutane while pregnant and had a child born with birth defects, you or they may be entitled to a large cash settlement. You may be able to obtain funds for further medical treatment Please read our terms and conditions. Your information will be kept private and confidential and used for the sole purpose of helping you learn your rights.  

Title:	Mr. Mrs. Ms.
First Name:
M. I.
Last Name:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Phone Number (day):
Phone Number (eve):
Email Address
If this inquiry is not for yourself, please tell us the name of the person?:
Title:	Mr Mrs Ms
First Name:
MI
Last Name:
What is the Injured's relationship to you?:	Self Mother Father Daughter Son Husband Wife Brother Sister Friend Other
Injured's Date of Birth? ie (mm/dd/19yy)
Have you or they taken Accutane?:	Yes No
Date(s) of use? (mm/yyyy - mm/yyyy)
What City and State Was Accutane Prescribed in?
Have you been diagnosed with any of the Following:
Inflammatory Bowel Disease (IBD)?	Yes No
Glaucoma?	Yes No
Crohn's Disease?	Yes No
Colitis?	Yes No
Bone Injuries or Disease?	Yes No
Date of Diagnosis?
Did you become pregnant or a father while taking Accutane or within 6 months of stopping Accutane?	Yes No
If you answered Yes:
Was the child born with birth defects?	Yes No
What is the Child's date of birth?
Did you receive any information about the use of Accutane and pregnancy?	Yes No
Did you sign a contract to use birth control, not become pregnant or a father while on the drug?	Yes No
Have you been diagnosed with depression?	Yes No
Was there a suicide or suicide attempt?	Yes No
If yes, date of incident?
What other side effects/injuries have you suffered from taking accutane?:
How did you or the Injured know accutane caused the situation?
When did you/Injured discover accutane caused the situation?
Do you or the injured currently have an attorney?	Yes No
If you or they experienced any other behavioral changes while on accutane, please describe them and your legal concern:
I understand that submitting this form does not create an attorney client relationship: Agree

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