Pharmacy/Pharmacist Error Questionnaire

Pharmacy error? Attorneys at our law firm have been interviewed by The New York Times, The Wall Street Journal, Lawyers USA and other publications. Attorneys Fred Pritzker, Elliot Olsen and Eric Hageman have been named "Super Lawyers" by Law & Politics magazine. To contact a prescription error lawyer at the firm, please call 1-888-377-8900 (toll-free), e-mail our attorneys, or sumbit our free case review form.

We are a national law firm representing pharmacy error victims throughout the United States. Below is a questionnaire you can print, complete and mail to our offices: Pritzker Olsen, P.A., Plaza VII, Suite 2950, 45 South Seventh Street, Minneapolis, MN 55402-1652. If you would prefer to fax, our fax number is (612)338-0104.

Name___________________________________
Address_________________________________
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Email address____________________________
Telephone numbers

Home_____________________
Cell_______________________
Work______________________

Age ____________
Date of birth_______________
State in which incident occurred______________
Name and address of pharmacy responsible for error___________________________________
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Name and correct dosage of medication you were supposed to have received____________________________
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Name and dosage of medication you actually received________________________________
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When did you start taking the wrong medication/dosage________________________
When did you stop taking the wrong medication/dosage________________________
How much of the wrong medication/dosage did you take_________________________________
How did you find out you were taking the wrong medication/dosage________________________
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Do you still have the container in which the wrong medication/dosage was given to you (please make sure you keep it along with any receipts, instructions or bills that accompanied it)________
Describe your symptoms caused by taking the wrong medication/dosage________________________
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What other harms and losses did you experience as a result of taking the wrong medication/dosage________________________
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Have you reported this error to the pharmacy? What did they tell you?___________________________________
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Has any doctor or other health care provider told you whether you will have long-term problems because of this error? If so, what did s/he tell you?___________________________________
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This is attorney advertising. Past results do not guarantee a similar outcome. The result of each case is determined by the specific facts and the applicable law.