Rochon Genova | Toronto Class Action Law Firm | Current Class Actions | AMO Solution

AMO Solution Class Action Questionnaire

Please provide the following information. Please note: This is for information gathering purposes only. This is not a claim form for compensation.

Rochon Genova will protect your name and all confidential information you submit against disclosure, publication or unauthorized user to the full extent under the law.

There is no charge or obligation for our review of your situation.

Once we have received your completed questionnaire, someone from our office will contact you with further information in the coming weeks.

Name of Product Used:

Do you still have the product or proof of purchase:

If yes, please indicate what documentation you have to support your purchase:

How long did you use this product?

How often did you use this product?

Description of infection or illness:

Description of required treatment:

Prognosis (if known):

Was surgery required? If so, please describe:

Name, address and phone number of Ophthalmologist:

Name, address and phone number of Family physician:

Summary of Expenses for treatment, medications, etc. (please list each item and the associated expense):

Other comments:

Tell us how to get in touch with you:

Name
E-mail
Adress 1
Address 2
City and Province
Postal Code
Tel
FAX

Please contact me as soon as possible regarding this matter.