Rochon Genova | Toronto Class Action Law Firm | Current Class Actions | Moore v. Kingstone

Moore v. Kingstone 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 form, someone from our office will contact you with further information in the coming weeks.

Name and Address of Family Physician:

Name and Address of Physician who referred to Dr. Kingstone (if different from above):

Date of first appointment with Dr. Kingstone:

Length of time in Dr. Kingstone's care:

Medications Prescribed by Dr. Kingstone:

Length of Time Medications were Ingested:

Describe the Physical and Psychological Effects of Medications Prescribed by Dr. Kingstone:

Additional Comments on the Effects of Medications Prescribed by Dr. Kingstone:

Date of last appointment with Dr. Kingstone?

Describe Additional Treatment Undertaken because of Drug Dependency or Addiction:

Name(s)/Address(es) of Other Physicians Involved in Care and Treatment Related to Drug Dependency and Addiction:

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