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3200 Travis : 3rd Floor
Houston, TX 77006
(713) 529-0025
(713) 751-0412 (fax)

Galveston
(409) 762-9090

Toll Free
888-529-4688

andrewsteinberg@lawyer.com
www.thesteinberglawfirm.com

Free Case Review
Fill out the form below if you need additional information or want to discuss a potential claim with an attorney. All inquiries are kept strictly confidential.

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Contact Information
* Title:
* First Name:
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* Relationship to Chantix User:
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Case Information

Name of Chantix User:

Date of birth of Chantix patient (mm/dd/yyyy):

Age of patient when Chantix was prescribed (mm/dd/yyyy):

Was suicide attempted after taking Chantix?
Yes
No

Did attempted suicide result in death?
Yes
No

Was hospitalization or institutionalization required after taking Chantix?
Yes
No


Were you on Chantix at the time of attempted suicide or hospitalization?
Yes
No
When did this occur?