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Full Name:
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City & State
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Email Address:
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Home Phone #
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Cell / Work Phone (Optional)
Name & Age of person with SJS / TENS
 *
What were you diagnosed with?
Stevens Johnson Syndrome (SJS)
Toxic Epidermal Necrolysis Syndrome (TENS)
Lyell's Syndrome
Other
Date that SJS type symptoms first appeared (Approximate)
 *
Date you were diagnosed with SJS or TENS ? (Approximate)
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Select State in which you were diagnosed:
Name of Drug you believe caused your SJS or TENS:
Dilantin (phenytoin)
Dilantin (Generic)
Tegretol (carbamazepine)
Tegretol (Generic)
Levaquin (levofloxacin)
Levaquin (Generic)
Lamictal (lamotrigine)
Parts of your body effected and description of injuries:
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Have you been hospitalized or had surgeries due to SJS or TENS? Please give details.
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Willis Law Firm - Houston, Texas - Product Liability Attorney - Free Stevens-Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis Syndrome (TENS) Dilantin Lawsuit, Tegretol SJS Lawsuit, Lamictal SJS Lawsuits & Levaquin SJS TENS Lawsuit & Class Action Litigation Consultation Nationwide


   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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