This form takes about 1-3 minutes to complete. You may be entitled to significant compensation.

Have you taken any of the following prescription medications? (Select all that apply) *

After taking this medication, were you diagnosed with NAION (Non-arteritic Anterior Ischemic Optic Neuropathy)? *

NAION (Non-Arteritic Anterior Ischemic Optic Neuropathy) is a sudden, painless loss of vision caused by reduced blood flow to the optic nerve. It is typically diagnosed by an eye doctor or neurologist. If you have not been specifically diagnosed with NAION by a medical professional, you may not qualify for this case review."

What state were you in when you took the medication? *

Approximately when did you begin taking this medication? *

Estimated dates are acceptable...

Approximately when did you stop taking this medication? *

What is the name of the doctor that prescribed you this medication? *

What is the name of the hospital/clinic that prescribed you this medication? *

Where is this hospital/clinic located? *

What is the name of the pharmacy that dispensed your medication? *

Where is this pharmacy located? *

What is the date of your NAION diagnosis? *

What is the name of the doctor that diagnosed you with NAION? *

What is the name of the hospital/clinic that diagnosed you with NAION? *

Where is this hospital/clinic located? *

Are you currently being represented by an attorney or another law firm for this matter? *

Full Name *

Email *

Phone *

Date of birth *

Address

Street Address *

City *

State *

Postal Code *

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