◊ INTRODUCTION
◊ AMENDED STATEMENT OF
   CLAIM
◊ PROVING THE CLAIM
◊ HEALTH CANADA REVIEW
   PANEL
◊ MERCK PRODUCT CIRCULARS
◊ PRODUCT RECALL NOTICES
◊ YOUR PERSONAL CLAIM

   (submit details of your claim)
 
◊ RETURN TO MAIN

Please complete this form to provide us with your claim information so we may answer any questions you may have and enter your claim details in the Vioxx Class Action claim file. It is not necessary that all of the questions on the form be answered at this time.

There is no charge or obligation on your part in completing this form. The personal information you submit in this form insofar as it identifies you personally is confidential.

First Name
Last Name  
Address
City   Prov
  Postal Code
Email Address
Home Phone Number
Work Phone Number
Date of Birth
Day:
Month:
Year:
If you are completing this form for another person, please indicate your name and relationship with the other person and your contact information (if different)
 

When did you start taking Vioxx?
When did you stop taking Vioxx?
If unsure, approximate number of months you took Vioxx:
For which of the following conditions did you start taking Vioxx?
Osteoarthritis Rheumatoid Arthritis Juvenile Rheumatoid Arthritis
Severe Menstrual Cycles Migraines Acute Pain
Other:
How did you first learn about Vioxx?

Doctor   Pharmacist   Advertisement by Merck  
Word of Mouth   Other:
How significant were the following in your first learning about Vioxx and taking Vioxx?
Doctor: Great Significance  
Little Significance  
No Significance  
Unsure  
Pharmacist: Great Significance  
Little Significance  
No Significance  
Unsure  
Advertisement by Merck: Great Significance  
Little Significance  
No Significance  
Unsure  
Other: Great Significance  
Little Significance  
No Significance  
Unsure  
When you started taking Vioxx did you have any reason to believe Vioxx could increase risk of heart attack, stroke or other negative effect on your health?

No   Yes (if yes, explain below) 
 
Did you read anything about Vioxx before you started taking it or after you stopped taking it?

No   Unsure   Yes (if yes, choose sources below) 
 Merck patient product information
 Merck advertising
 Pharmacy information sheet
 Information in product box
Did you have any of the following conditions prior to taking Vioxx?
Heart Attack (Please Explain)
Stroke (Please Explain)
High Blood Pressure (Please Explain)
High Cholestrol Level (Please Explain)
Other (Please Explain)
Details of relevant family medical history including heart attack and stroke:
How often did you use Vioxx?

Daily during the whole time I was taking Vioxx   Varied (if so, explain below) 
 

Was your dosage 25 mg / day?  
If not, or if it varied, please provide details 
 
Why did you stop taking Vioxx?
Personal Decision (Please Explain)
Doctor's Advice (Please Explain)
Pharmacist's Advice (Please Explain)
Recall notice of Vioxx on September 30, 2004
Have you had one or more of the following conditions since taking Vioxx?
Heart Attack Stroke      Blood Clot
Increased Blood Pressure Vision Impairment  
Other:
When did you first have one of these conditions:
If unsure please estimate the number of months:
Details of hospitalization, surgery, procedures or other treatments potentially related to Vioxx:


Names of Hospitals (if applicable)

Details of ongoing treatments, tests and follow-ups for conditions potentially related to Vioxx:
Have you seen one or more of the following doctors for a condition that may be related to Vioxx? (We will not contact any of these individuals without your permission.)
Cardiologist
Yes   No   Unsure
Name:
Location:
Cardiovascular Surgeon
Yes   No   Unsure
Name:
Location:
Neurologist
Yes   No   Unsure
Name:
Location:
Neurosurgeon
Yes   No   Unsure
Name:
Location:
Hematologist
Yes   No   Unsure
Name:
Location:
Opthamologist
Yes   No   Unsure
Name:
Location:
Internist
Yes   No   Unsure
Name:
Location:
Other Specialist
Type:
Yes   No   Unsure
Name:
Location:
Name of your family doctors since you started Vioxx
Name:
Name of your pharmacists since you started Vioxx
Name:
What medications are you taking that may be related to Vioxx?
Medication:
Purpose:
Dosage:
Side Effects:
  Permanently   Temporarily   Unsure
 
Medication:
Purpose:
Dosage:
Side Effects:
  Permanently   Temporarily   Unsure
 
Medication:
Purpose:
Dosage:
Side Effects:
  Permanently   Temporarily   Unsure
How do you think Vioxx has affected your life and activities?
If you lost time from work related to Vioxx, please indicate:
Occupation:
Details:
Would you like to be contacted by one of our lawyers at this time?

Yes    No 
If so, we will contact you by phone to discuss your claim and, where appropriate, to schedule a personal consultation at our office.
 
There is no charge or obligation for any such contact or consultation payable by you at this time. We will be paid only if the class action is successful. In that case, our fees will be paid from the settlement or judgment.
Do you have any specific questions for us?
If there are any further changes in your health that we should know about, please contact us. You may resubmit the relevant sections of this form or call us. If you are resubmitting your form for this reason please check the following box (it may take a couple of days before we can respond to you):

Vioxx follow-up:  
 
This website will contain future developments on the Vioxx class action.

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