Mirena Lawsuits

Houston

3200 Travis : 3rd Floor
Houston, TX 77006
(713) 529-0025
(713) 751-0412 (fax)

Galveston

(409) 762-9090

Toll Free

888-529-4688

andrewsteinberg@lawyer.com
www.thesteinberglawfirm.com

Mirena

Free Case Review

Fill out the form below if you need additional information or want to discuss a potential claim with an attorney. All inquiries are kept strictly confidential.

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Contact Information
* Title:
* First Name:
* Last Name:
* Relationship to Testosterone Therapy Patient:
* Email Address:
* Phone:
* Phone (Cell):
* Address:
* City:
* State:
* Zip:

How would you prefer to be contacted?

Email Mail Phone
Case Information
Name of Testosterone Therapy Patient:
Date of birth of Testosterone Therapy Patient (mm/dd/yyyy):

Which of the following were used in the Testosterone Therapy?

Androgel
Androderm
Axirom
Bio-T-Gel
Delatestryl
Depo Testosterone
Fortesta
Striant
Testim
Testopel

Age of patient when Testosterone Therapy began:

Did you or a loved one experience any of the following side effects or complications after Testosterone Therapy?

Stroke
Heart Attack
Death

Were you or a loved one on Testosterone Therapy at the time?
Yes
No

If no, how long since Testosterone Therapy ended?

Was medical care required after the Testosterone Therapy?
Yes
No

Were you on Testosterone Therapy at the time of medical care?
Yes
No
When did this occur?