LOCAL 409-203-5030
TOLL FREE 888-588-1695

Provost Umphrey 50th Anniversary

Hard-Working Lawyers for Hard-Working People

Testosterone-Questionnaire

Bold labels and This graphic indicates a required field. indicate required information.

Personal Information
Injury Information

Is the injured party Deceased

Have you been prescribed any of the following Testosterone Replacement Therapies?

Androgel-Gel

Androderm-Patch

Android-Pill

Axirom Gel

Bio-T-Gel

Cypionate-Injection

Delatestryl-Injection

Depo-Testosterone-Injection

Fortesta-Spray Gel

Striant-Gum Supplement

Testim-Gel

Testopel-Pellet

Other

Have you been diagnosed with any of the following injuries/conditions? Please check all that apply and provide the appropriate information:

Myocardial Infarction - (Heart Attack):

Stroke (includes mini-strokes/TIA's)

Pulmonary Embolism (PE/blood clot)

Deep Vein Thrombosis (DVT/blood clot)

Blood Clots

Privacy Policy