Do You Qualify?

Paxil Class Action

If you took Paxil during your pregnancy and your child was born with cardiac complications, please fill out the form and a member of the Klein Lyons team will call to discuss your case. All information is confidential.
[form_name formname=”Paxil Class Action”][/form_name]
[label name=”name” label=”Name *“][/label]
[su_row]
[su_column size=”1/2″]
[field_input name=”firstname” type=”name” label=”First” req=”required”][/field_input]
[/su_column]
[su_column size=”1/2″]
[field_input name=”lastname” type=”name” label=”Last”][/field_input]
[/su_column]
[/su_row]

[su_row]
[field_input name=”email” type=”email” label=”Email *“][/field_input]
[/su_row]

[su_row]
[su_column size=”1/2″]
[field_input name=”phone” type=”phone” label=”Phone Number *”][/field_input]
[/su_column]
[/su_row]

[su_row]
[label name=”address” label=”Address”][/label]
[/su_row]
[su_row]
[field_input name=”street_address” type=”address” label=”Street Address”][/field_input]
[/su_row]
[su_row]
[field_input name=”address_line2″ type=”address” label=”Address Line 2″][/field_input]
[/su_row]

[su_row]
[su_column size=”1/2″]
[field_input name=”city” type=”address” label=”City”][/field_input]
[/su_column]
[su_column size=”1/2″]
[field_input name=”state/province/region” type=”address” label=”State/Province/Region”][/field_input]
[/su_column]
[/su_row]

[su_row]
[su_column size=”1/2″]
[field_input name=”postal/zip_code” type=”address” label=”Postal / Zip Code”][/field_input]
[/su_column]
[su_column size=”1/2″]
[field_country][/field_country]
[/su_column]
[/su_row]

[su_row]
[field_input name=”date_started_paxil” type=”date” label=”Date you started to take Paxil:”][/field_input]
[/su_row]

[su_row]
[field_input name=”date_started_paxil” type=”date” label=”Date you stopped taking Paxil:”][/field_input]
[/su_row]

[su_row]
[field_text name=”story” type=”text” label=”Tell Us Your Story”][/field_text]
[/su_row]
[su_row]
[label name=”label” label=”How did you hear about Klein Lyons?”][/label]
[hear_about][/hear_about]
[/su_row]

[label name=”label” label=”Is it alright if we send you email updates?
You may withdraw your consent at any time.”][/label]
[su_row]
[field_bullet name=”email_updates” type=”bullet” label=” Yes”][/field_bullet]
[field_bullet name=”email_updates” type=”bullet” label=” No”][/field_bullet]
[/su_row]

[su_row]

[/su_row]

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