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First Name*:

Last Name*:

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Zip Code*:

Did you or a loved one use any of the following birth control? *:
---YAZYasminOcellaGianviNuvaringOther

Age when injured*:
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Are you a regular smoker?*:
Yes No 

Did you or loved one suffer any of the following injuries?*:
 DVT (deep vein thrombosis) PE (pulmonary embolism) Heart Attack Cardiovascular Injury Heart Arrhythmia Stroke Death Blood Clot Related Injury Kidney Failure Gallbladder Removal Vaginal Clot Gallbladder Injury Blood Clot (brain, lungs or body) Other

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When did you start taking Yaz/Ocella/Yasmin?*:

---2022202120202019201820172016201520142013201220112010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950

When did you stop taking Yaz/Ocella/Yasmin?*:

---2022202120202019201820172016201520142013201220112010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950

Please further describe Yaz injury:

Have you signed a contract with a lawyer to represent you on this case?*
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You understand and agree to the following: your case may be evaluated by an attorney. You may be contacted by a represenative of a firm about this matter and the submission of your information in no way constitutes an attorney-client relationship.