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Invokana Intake Form

Dangers of Diabetes Drug, Invokana

Your Name (required)

Your Email (required)

Phone

Address

Do you (or a loved one) have diabetes?
Type 1Type 2No

Which of the following diabetes drugs have you taken?

Medication Description

Date you began taking the medication

Date you stopped taking the medication

State perscribed

Do you suffer from any of the following?

Date and description of injuries:

If you were diagnosed with ketoacidosis, was the diagnosis, was the diagnosis made after January 2016?
YesNo

Have you consulted with any other law firms concerning this matter?
YesNo

Please enter any additional details you would like us to know about your submission