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Intake Questionnaire for Litigation Related to Ozempic and Similar Medications

We are investigating cases where the potential clients took name brand Ozempic, Wegovy, Rybelsus, Mounjaro, Saxenda, Trulicity, and Zepbound and were later diagnosed and treated for intraoperative pulmonary aspiration, ileus or bowel obstruction, gallbladder removal (if an Ozempic case, then the exposure must have been prior to the label change in March 2022), severe or permanent stomach paralysis, gastroparesis, other gastrointestinal injuries, acute necrotizing encephalopathy (ANE) (for non-Trulicity cases only), non-arteritic anterior ischemic optic neuropathy (NAION), or suicide. The PC must have had medical treatment or hospitalization for the injuries (except of course if the injury is suicide).

Personal Information

Mailing Address

Medication Usage

Which medication(s) have you or your loved one taken? (Check all that apply)

Medical History Related to Medication Use

Were you or a loved one diagnosed with any of the following conditions after taking the medication(s)? (Check all that apply)
Did you or your loved one receive medical treatment or hospitalization for any of the conditions listed above?

Additional Information

Did the patient undergo any of the following procedures prior to taking the medication(s)? (Check all that apply)
Are you currently receiving treatment for cancer?

Consent

Do you consent to sharing this information with our legal team for the purpose of evaluating your potential case?

Thanks for contacting us!

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