Houston
3200 Travis : 3rd Floor
Houston, TX 77006
(713) 529-0025
(713) 751-0412 (fax)

Galveston
 (409) 762-9090

Toll Free
 888-529-4688

andrewsteinberg@lawyer.com
www.thesteinberglawfirm.com

Free Case Review
Fill out the form below if you need additional information or want to discuss a potential claim with an attorney. All inquiries are kept strictly confidential.

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Contact Information
* Title:
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Case Information

Name of Chantix User:

Date of birth of Chantix patient (mm/dd/yyyy):
Age of patient when Chantix was prescribed (mm/dd/yyyy):

Did you or a loved one experience any of the following side effects after taking Chantix?

Heart Attack
Stroke
Attempted Suicide
Other Cardiovascular Problem

Did any of the side effects result in death?
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No

Was hospitalization or institutionalization required after taking Chantix?
Yes
No


Were you on Chantix at the time of attempted suicide or hospitalization?
Yes
No
When did this occur?