SHARE YOUR STORY Opioid Prescription Information Request Please be aware that providing this information does not obligate you for any cost or expense. It also does not create or obligate either party (you or us) to an attorney client relationship. In other words, we are not agreeing to represent you simply because you provide the information requested below. If you decide you want us to consider representing you for the potential claims and legal actions described here, and we agree to represent you, we, or an attorney licensed to practice in the state where you live to whom we might refer you, will provide you with a written representation agreement. Even if we do not represent you personally, the information you provide may be used in connection with any legal action undertaken as described here or possibly efforts for legislative remedies, but your personal information will not be shared outside of our legal team without your permission. HOWEVER, BE AWARE THAT WHILE WE WILL TAKE STEPS TO ENSURE CONFIDENTIALITY, THE CONFIDENTIALITY OF COMMUNICATIONS SENT THROUGH THIS WEB SITE CANNOT BE GUARANTEED, SO IF YOU WOULD PREFER TO SHARE CERTAIN INFORMATION WITH US PRIVATELY, PLEASE LET US KNOW BY SENDING US ONLY YOUR NAME AND PREFERRED CONTACT INFORMATION.Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email PhoneHow did you hear about us?GoogleFacebookOther Social MediaWebsiteFriend or Family MemberOtherAre you a (check all that apply)? Select All Medical Doctor Pharmacist Sufferer of Chronic Pain Patient w/cancer diagnosis Patient receiving palliative or nursing home care Sickle Cell patient Legal Guardian of patient Caregiver of patient Osteoarthritic patient Cause of Chronic Pain8. When did treatment of chronic pain, sickle cell pain, cancer diagnosis, palliative or nursing home care begin? Date Format: MM slash DD slash YYYY Has the pain ended? Yes No If pain has ended, when? Date Format: MM slash DD slash YYYY 10. Have you had difficulty receiving legitimate prescriptions for opioid medication filled as written at any Pharmacies? Yes No a. At which Pharmacies did you have such difficulty? (check all that apply) Walgreens CVS Rite-Aid Other If other, please list.b. For each Pharmacy checked, what was the problem you encountered at the Pharmacies? (Identify all pharmacies to which any of the following apply.) Refusal to fill Reduced number of pills prescribed Reduced prescription strength Required additional prescriptions Delayed Filling of prescription Blacklisted Humiliated or belittled you Restriction on prescribing doctor Restriction based on location of prescribing doctor Other If other, please describe allWhat actions did you take to get your prescription filled?When did the listed problem begin?e. For each Pharmacy at which you encountered problems filling your legitimate prescriptions for opioid medication, please provide its name, street address, if possible, and city of the pharmacies.Did you incur any additional out of pocket expenses in connection with your problems in filling your legitimate prescriptions for opioid medication as written?YesNoIf Yes, describe the nature and amount of additional expenses to the best of your ability.12. Please describe in detail your experiences and the pain they have caused you.13. Have you suffered a condition requiring emergency medical care as a result of the denial or limitation of your prescription medication. If yes, please explain14. Have you attempted or considered suicide as a result of the denial or limitation of your prescription medication. If yes, please explain:15. May we contact you about your experience?YesNoIf Yes, please provide your preferred contact information and hours of contact.Time : HH MM AM PM 16. Are you willing to act as a class representative in a class action lawsuit?YesNo17. Are you seeking to pursue legal action as a result of your experiences?YesNo