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Opioid Overdose QuestionnaireChris2019-01-30T00:32:14-05:00

Opioid Overdose Questionnaire

Please Take A Moment To Fill Out This Questionnaire

Name Of Decedent*
First Last
Contact's Name*
First Last
Primary Phone*
Secondary Phone
Email*
Enter Email Confirm Email
Relationship To Decedent*
Date Of Death*
Date Format: MM slash DD slash YYYY

**There Is A 2 Year Statute Of Limitations. If It's Past 2 Years We Have No Case
Do You Have The Autopsy Report*
- Yes
- No
- Unknown
**If Not It Will Need To Be Obtained
Was Decedent On Prescription Opioids?*
- Yes
- No
If So, Do You Know What He/She Were Taking And How Long?*
- Yes
- No
- Unsure
Please List The Opioids (If Known) And Amount Of Time Taken:
Do You Know Who Prescribed And What Was The Reason They Were Prescribed?*
- Yes
- No
- Unknown
Please Provide Name(s) And Reason(s):
Do You Know The Pharmacy (Or Pharmacies) That Decedent Obtained Their Prescriptions From?*
- Yes
- No
Name(s) Of Pharmacy:*
Once We Get The Autopsy Report That Will Have The Toxicology On It, We Can Determine The Validity Of The Case. To Expedite The Process, Please Obtain A Copy Of The Autopsy Report From The Coroner.

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833-OD-DRUGS
(833-633-7847)

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THERE ARE NO OUT OF POCKET COSTS FOR YOU
WE WORK ON A CONTINGENCY FEE BASIS

Our Attorneys

John Larson, Esq.

John Larson, Esq.Attorney

Licensed in Illinois
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Jim Magazine, Esq.

Jim Magazine, Esq.Attorney

Licensed only in Florida
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Elizabeth Pekin, Esq.

Elizabeth Pekin, Esq.Attorney

Licensed in Illinois, Of Counsel
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Jeff Lucas, Esq.

Jeff Lucas, Esq.Attorney

Licensed only in Florida
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