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)? *

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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