Name* A value is required.Please include your name.
Address
City State Zip Code
Phone* A value is required.Please include a valid phone number
Cell Phone
Best Time to Call
email* A value is required.Please include a valid email address

Are You Registered with the Fen-Phen Settlement ?* not answered Yes No Unsure Please select yes or no
Do You Have a Claim Number ? Yes No Unsure
Do You Know Your Status in the Fen-Phen Settlement? No Mild MR FDA Positive Green Form 7th Amendment
In What Year Did You Last Use Fen-Phen? Not Sure Before 1992 1992 1993 1994 1995 1996 1997 1998

Have You Had Heart Valve Surgery? Yes Not yet, but I am scheduled for surgery Not yet, but my doctor thinks I will need surgery No

Have you suffered or had any of the following (check all that apply)
Stroke Heart Attack Heart Transplant Heart-Related Organ Failure
Atrial Fibrillation Irreversible Pulmonary Hypertension
Ventricular Fibrillation Ventricular Tachycardia
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