Opioid Lawsuit Qualification Form

Opioid Lawsuit Qualification Form

Answer a few short questions to see if you potentially qualify for this lawsuit.
Did you or your loved one take opioids prescribed for you OR did you or your loved one take opioids prescribed for someone else? *

Yes No
Did you or your loved one become opiate dependent? *

Yes No
Did you or your loved one overdose from opioids? *

Yes No
Did your loved one pass away from his/her opioid addiction? *

Yes No Not Applicable
Please provide us with contact information so that our legal team may contact you to discuss your potential case.
Name *

First Name Last Name
Email
example@example.com
Phone Number *

Area Code Phone Number

Address