Home » Invokana Intake Form
Your Name (required)
Your Email (required)
Do you (or a loved one) have diabetes?
Type 1Type 2No
Which of the following diabetes drugs have you taken?
InvokanaInvokametInvokament XRFarxigaXigduo XRJardianceGlyxambi
Date you began taking the medication
Date you stopped taking the medication
Do you suffer from any of the following?
Amputated toeAmputated FootAmputated Leg (below the knee)Amputated Leg (above the knee)Diabetic KetoacidosisDiabetic Coma
Date and description of injuries:
If you were diagnosed with ketoacidosis, was the diagnosis, was the diagnosis made after January 2016?
Have you consulted with any other law firms concerning this matter?
Please enter any additional details you would like us to know about your submission
Larry Wall Trial Law
121 S. Whittier St.
Wichita, KS 67207