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The Nations Law Firm
4515 Yoakum Boulevard
Houston, Texas 77006
713 807.8400
toll.free 800 269.3050

SUBMIT A POTENTIAL CASE:
FOSAMAX, ZOMETA & BISPHOSPHONATES

Thank you for giving us the opportunity to review your potential claim. An attorney will contact you promptly to gather further information and to discuss your case with you. There is no charge for this evaluation.

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Title

First Name (Required)*

Last Name (Required)*

Email Address (Required)*

Please Re-type Email Address

Street Address (Required)*
Apt./Suite

County

City (Required)*

State or Province (Required)*

Zip Code (Required)*

Country if other than the U.S.

Office Phone Number including Area Code (Required)*

Home Phone Number including area code

Cell Phone Number including area code

Best way to contact you
(Please provide best place, time, method of reaching you)

Have you contacted any other lawyers about this matter?
Yes No

Are you currently represented by an attorney? (Required) *
Yes No

Your Case Information

Are you the injured person?
Yes No

If not, please state the name of the injured person and their relationship to you.
Name
Relationship

Please describe the nature of your complaint in one brief sentence.

Date of Birth of the Injured Person: (mm/dd/yyyy)

Which of the following medications did you take? (check all that apply)

Fosamax (Alendronate Sodium)

Zometa (Zoledronate)

Didronel (Etidronate)

Aredia (Pamidronate)

Actonel (Risedronate)

Boniva (Ibandronate)

Skelid (Tiludronate)

Other bone density medication

Not Sure

If Other, please describe:

How did you take the medicine?

Intravenously (by IV)

Orally (by mouth)

Other

Not Sure

When did you take each of the above medications?

(month and year)

Where did you live when you took these medications?

(city and state)

After you started taking the medicine, did you experience any of the following?

jaw pain

toothache

swelling in the jaw area

loosening of the teeth

exposed jaw bone

altered sensation in the jaw area

severe bone, muscle or joint pain

not sure

none of the above

If so, when did this occur?

(month and year)

Where did this occur?

(city and state)

Have you been diagnosed with osteonecrosis?

Yes

No

Not Sure

If Yes, when were you diagnosed?

(month and year)

Did you have any dental work done while you were taking the medications or after you stopped taking them?

Yes

No

Not sure

Additional Details Related to Your Case:

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