Plaintiff Personal Injury Drug

Tardive Dyskinesia Form

NOTE: An Asterisk (*) Indicates REQUIRED Information.

Date of Contact:
*Client Name:

DRUG (S):
Duration of Exposure:
Date of 1st exposure
Date of Last Exposure
Date of Discovery of TD:
Defendant Doctors:
Psychiatric Diagnosis:
Hospitalizations (how many/how long):
Alleged Indication for Neuro:
Type of Movement/Severity:
TD Verified by Diagnosis: Yes No By Whom:
Description of TD Treatment:

Note:

By sending this e-mail, I acknowledge that I have read and agree to the following: No attorney-client relationship is established. I have not engaged McGlynn, Glisson, and Mouton Law Firm or any affiliated attorney to represent me, and neither McGlynn, Glisson, and Mouton Law Firm nor any affiliated attorney does represent me until such time as McGlynn, Glisson, and Mouton Law Frim and I have both signed a WRITTEN CONTRACT OF ENGAGEMENT.