Follow Petroff & Associates Follow Petroff & Associates on Facebook Follow Petroff & Associates on Twitter

3838 Oak Lawn Ave.
Suite 1620
Dallas, Texas 75219
214-526-5300
1-888-710-1366
View Google Map


About Fen-Phen Fen-Phen Settlement If You Took Fen-Phen For Doctors / Lawyers

Fen-Phen Questionnaire

If you (or a loved one) are a member of the Fen-Phen Class Action Settlement, please fill out this form:

PART ONE: INSTRUCTIONS

The following questions are designed to allow us to determine if you (or your loved one) have a potential diet drug Seventh Amendment High Level Claim (Seventh Amendment Claim). All of these questions are important. We realize that you may not know the answers to all questions. Please answer all questions to the best of your ability.

You may submit this Questionnaire in one of two ways:

1. Online: Please fill out the form below and hit the "Send" button at the bottom, or

2. By Mail: If you prefer, you may print this questionnaire and mail it to:

Petroff & Associates 3838 Oak Lawn Ave. Suite 1620, Dallas, TX 75219

Our Response Time: We try to respond promptly to all Questionnaires from prospective clients, but we sometimes cannot meet that goal. Please make sure to follow up with us if you haven’t heard back from us within three business days of submitting this Questionnaire online, or within one week of submitting this Questionnaire by postal mail.

PART TWO: PERSONAL BACKGROUND INFORMATION
First Name: *(Required)
Last Name: *(Required)
E-mail Address: *(Required)
Confirm E-mail Address:
Mailing Address:
City:
State:
Zip Code:
Phone:
How would you prefer that we contact you? E-mail
Phone
Mail
Any of the above

PART THREE: CLAIMS INFORMATION
1. Did you register with the AHP Settlement Trust by filing a "Pink" Form, "Blue" Form or "Green" Form on or before May 3, 2003? Yes
No
Don't Know
Not Answered
2. Did you have an echocardiogram performed before January 3, 2003 (or by July 3, 2003 if echocardiogram performed by AHP Trust)? Yes
No
Don't Know
Not Answered
3. Did you take either Pondimin or Redux? Yes
No
Don't Know
Not Answered
3a. If you took either Pondimin or Redux, do you have written proof or a written record that proves you took either one of these diet drugs? Yes
No
Don't Know
Not Answered
4. Have you received any amount of money from either the AHP Settlement Trust or from the Seventh Amendment Fund Administrator? Yes
No
Don't Know
Not Answered

5. Did the AHP Settlement Trust assign you a "Diet Drug Recipient Number" (DDR Number)?

Yes
No
Don't Know
Not Answered

If "Yes," please enter your DDR # below:

6. If you are answering this questionnaire on behalf of a person who is deceased, did this person die suddenly as a result of a heart condition? Yes
No
Don't Know
Not Answered
PART FOUR: MEDICAL HISTORY QUESTIONS
7. Have you had any episodes of ventricular fibrillation or ventricular tachycardia? Yes
No
Don't Know
Not Answered
8. Have you had surgery to repair or replace your mitral heart valve or your aortic heart valve? Yes
No
Not Answered

8a. If you had surgery, what was the date of the surgery?
9. Has your cardiologist recommended that you undergo heart valve surgery? Yes
No
Don't Know
Not Answered
(To list more information, please use the text box below).

PART FIVE: CONCLUSION

COMMENTS/QUESTIONS:

We realize that you may want to tell us something about your claim that may not have been asked above. You can use the space below for that purpose. Thank you for your interest in our firm possibly representing you in your potential Seventh Amendment Claim.

Please type your comments and/or questions below:
characters left

*Please ensure that you have filled in your name and e-mail address at the top (marked “Required”).

By submitting this Fen-Phen Questionnaire, you certify that you agree to our Terms of Use (TOS) (click to view our TOS in a new window) and wish to be contacted regarding your inquiry.

          

 


Fen Phen Questionnaire
Contact Us

 

More On Fen-Phen:

 

 

We Are Fen-Phen Lawyers.

Fen-Phen News:

Deadline For Compensation

GENERAL WARNING for ALL Seventh Amendment Claimants (Category One or Category Two Claimants); to meet the deadline for compensation, the medical condition that qualifies you for Matrix Level III, IV or V benefits must be diagnosed and also occur by the earlier of December 31, 2011, or fifteen years from the last date of diet drug use. If you fail to meet this deadline, you will never be able to make a claim for compensation for damages arising from your use of Pondimin® or Redux™ (Fen-Phen), either from the Trust or through any independent lawsuit, even if you later develop a Matrix III, IV, or V condition.