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A CASE FOR WOMEN – Elmiron Questions
Questions? Call us at
(888) 373-7888
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PERSONAL AND CONFIDENTIAL – PROSPECTIVE CLIENT COMMUNICATION
Elmiron Questions
Were you prescribed Elmiron?
*
Yes
No
Please explain:
*
Hidden
(DEL)Month prescribed
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Hidden
(DEL)Year prescribed
Year:
-select-
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
How long did you take it for?
*
(Please list a date range if you know it.)
If you have stopped taking Elmiron, what age were you when you took Elmiron?
*
(Please list a range if applicable)
What state were you prescribed Elmiron in?
*
- Select -
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
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Why were you prescribed Elmiron?
*
Prescription Details
When were you prescribed Elmiron?
If you are unsure, an approximate date is fine.
Month prescribed
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year prescribed
*
Year:
-select-
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
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1924
1923
1922
1921
1920
1919
1918
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1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Name of doctor:
Facility:
*
Medical Info
Are you experiencing any of the following symptoms?
*
Please check all that apply:
Difficulty reading
Difficulty adapting to dim lighting
Blurred vision (often centrally in the patient's field of vision)
Dark spots in center of vision
Straight lines appearing curved or squiggly
Muted, less vivid colors
Vision Disturbances
Distorted Vision
Vision Loss
Other
None of the above
Please explain:
*
Have you been diagnosed with any of the following:
*
Maculopathy
Retinal Maculopathy
Macular degeneration
Pattern dystrophy
Retinal disease
Pigmentary maculopathy
Retinal tear or detachment
Macular hole or degeneration
Epirentinal membrane
Other
None of the above
Please explain:
*
When were you diagnosed?
If you are unsure, an approximate date is fine.
Month:
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year:
*
Year:
-select-
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Name of doctor:
*
Facility:
*
Do you have an upcoming appointment with your doctor about this?
*
Yes; I have an upcoming appointment
No
I haven’t gone to the doctor yet but I intend to
Date of next doctor appointment:
If you are unsure, an approximate date is fine.
Month next appointment
Month:
-select-
January
February
March
April
May
June
July
August
September
October
November
December
Year next appointment
*
Year:
-select-
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Name of doctor:
*
Facility:
*
Any other details?
*
Is there anything else you’d like us to know?
*
Personal Details
Did you have to stop working or take time off work because of your symptoms?
*
Yes
No
Marital Status
*
Single
Married
Separated
Divorced
Widowed
If you have a different last name that may be on your medical records, please list it here:
Hidden
(DEL) Full name of spouse:
Do you possess copies of your medical records that relate to Elmiron and your related symptoms/treatment?
Yes
No
Unsure
Please explain:
*
Hidden
Contact Info
Contact Info
Please fill in the remaining questions below with your own contact information
Your Full Legal Name:
First Name
*
Middle Name
Last Name
*
Email
Cell Number
*
Address
*
Street Address
City
ZIP / Postal Code
State
*
-Select-
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
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
If we are unable to reach you, who can we contact in the case of an emergency?
Their phone number:
*
Their email address:
*
If we can’t reach you, is it okay for us to reach out privately via social media?
*
Yes
No
Please list the social media platform and your username:
Anything else we should know?
Are you currently represented by another law firm to pursue legal action for your Elmiron case?
*
Note: This does not pertain to any suit against a doctor or hospital/facility.
Yes
No
Amazing! We're so happy that you're standing up for yourself, and everyone hurt by Elmiron. You can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.
Great! We're so happy you're interested in standing up for yourself, and everyone hurt by Elmiron. Just so you know, you can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.
IPQS
Name
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