Home ยป Invokana Intake Form
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? InvokanaInvokametInvokament XRFarxigaXigduo XRJardianceGlyxambi
Medication Description
Date you began taking the medication
Date you stopped taking the medication
State perscribed
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? 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
Larry Wall Trial Law 121 S. Whittier St. Wichita, KS 67207 (316) 265-6000 (800) 475-4140 View Map
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