HMG Opioids Case Update - Hilliard Martinez Gonzales LLP

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Case Number

First Name*

Last Name*

Last 4 of SSN*

Are you the person who used opioids? IF YOU ARE BRINGING SUIT OR FILING A CLAIM ON YOUR OWN BEHALF FOR YOUR USE OF OPIOIDS AND YOU ARE BRINGING SUIT OR FILING A CLAIM ON SOMEONE ELSE’S BEHALF BECAUSE THEY USED OPIOIDS OR DEVELOPED NEONATAL ABSTINENCE SYNDROME, PLEASE COMPLETE THIS FORM TWICE, ONCE FOR YOURSELF AND ONCE FOR THE OTHER PERSON ON WHOSE BEHALF YOU ARE BRINGING A SUIT OR FILING A CLAIM.

Yes
No
N/A

If you are not the person who used opioids, check all that apply:

If you are bringing suit or filing a claim on behalf of someone else, what is that person’s name?

If you are bringing suit or filing a claim on behalf of someone else, what is your relationship to that person. Please check all that apply:

If you are suing or filing a claim on behalf of a child, are you that child’s legal guardian?

Yes
No
N/A

If you are suing or filing a claim on behalf of a child, did that child develop Neonatal Abstinence Syndrome?

Yes
No
N/A

If you are filing a suit or bringing a claim on behalf of someone who has died as a result of or in connection with opioid use, have you been formally appointed by a court or a judge as the Personal Representative or Executor of the deceased person’s estate? If not, then please state whether an estate has been opened, and if an estate has been opened state the first and last name, address, and telephone number of the individual who has been appointed as the Personal Representative or Executor.

Year of birth of the person who used opioids (or fetus who was exposed in the uterus):

Last four digits of the person who used opioids (or the fetus who was exposed in the uterus) SSN:

Which of the following injuries did the person who used opioids (or the fetus exposed in the uterus) suffer.Please check all that apply.

Other injury description:

If the injured person was exposed to opioids as a fetus before birth, and developed neonatal abstinence syndrome, what kind of neonatal abstinence syndrome did he or she develop? Please check all that apply.

Not including this claim or lawsuit, have you ever filed a lawsuit against Purdue or any other manufacturer of opioid medication?

Yes
No
N/A

If yes, then please provide the following information [Case Caption] and [Court and Case/Docket number]:

Attorney Information (Law firm name; Attorney Name, Address, City, State, Zip code, Contact Phone, Contact email):

Were you prescribed or administered a Purdue brand name opioid by a healthcare professional?

If yes, please indicate which Purdue opioid you were prescribed or administered Butrans? Please select all that apply.

Were you prescribed or administered any opioid other than a Purdue brand name opioid by a healthcare professional?

Yes
No
Unknown

If yes, please indicate which Non-Purdue Brand Name Opioid, if known:

Please identify the generic opioid(s) that you (or the person on whose behalf you are filing this claim) were prescribed or administered by a healthcare professional (PLEASE CHECK AS MANY MEDICATIONS AS APPLICABLE):

Other generic type:

Email

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