Rochon Genova | Toronto Class Action Law Firm | Current Class Actions | Oxycontin

Oxycontin 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.

Date of first Oxycontin ingestion:

Do you still have the product or proof of purchase:

Please state the reason for your use of Oxycontin:

How long did you ingest Oxycontin?

How often did you ingest Oxycontin?

Are you still ingesting Oxycontin?

Please list all of your current medications:

If not still using OxycontinÂ®, what symptoms were experienced from discontinuing OxycontinÂ®?

Name, address and phone number of treating physician:

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.