If you have concerns about taking OXYCONTIN, please complete the form below and we will review your information and contact you. Required Fields are marked with a blue dot, and all YES or NO questions must be answered. Required Fields First Name: Middle Name: Last Name: Address: Mailing Address:(if different from above) City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY b154ew04 Zip: Phone (include area code): Work Phone (include area code): Other Phone (family, pager, cellular): Email Address: Date of Birth (mm/dd/yyyy): OXYCONTIN SPECIFIC QUESTIONS: Please answer below. Are you now or have you ever taken OxyContin?   YES      NO  If you answered YES, for what medical condition were you taking OxyContin? When did you start taking the drug? (mm/dd/yy) How long did you take the drug? When did you stop taking the drug? What was your dosage? Were they ever increased / decreased? If so what was the reasoning? Are you still taking the drug OxyContin?   YES      NO  What is the name of the doctor(s) that prescribed the OxyContin? Please include name, address, and telephone. buy essays of unsurpassed quality created by top pros in the industry at EssaysMonster.com. Has the use of OxyContin resulted in a death?   YES      NO  If you answered YES, What is the name of the deceased? What is your relationship to the deceased? What caused their death and when? Are you now or have you ever been addicted to OxyContin? If so, please describe. Have you already retained an attorney for this case?   YES      NO  If YES, provide the complete name, address and telephone for the attorney. How did you hear about our lawfirm? (please be specific)

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Pikoff & Riff, L.L.P. Attorneys At Law 440 Louisiana, Suite 1818 Houston, Texas 77002 Toll Free: (800) 240-2460 Fax: (713) 237-0278 info@AboutOxyContin.com The information contained in this website is for informational purposes only and is not intended to be legal advice. The attorney-client relationship can only be formed by written agreement of the parties. All trademarks are the property of their owners. Pikoff & Riff, L.L.P. is not affiliated with the manufacturer of OxyContin, nor is this website affiliated, sponsored, or endorsed by Purdue Pharma L.P. The attorneys of Pikoff & Riff, L.L.P. are licensed to practice law only in the State of Texas. Other lawyers likely to be associated with the handling of these claims. Not certified by the Texas Board of Legal Specialization.

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