Zapier Integration Page – National Injury Help

* Was the person prescribed Xarelto a male or female?
- Male
- Female

* 2. Was the patient hospitalized due to a bleeding event while using Xarelto?
- No
- Yes

* 3. Was the patient hospitalized for more than 2 days due to a bleeding event?
- No
- Yes

* Why was the patient hospitalized?
- Gastrointestinal Bleeding
- Intracranial Bleeding
- Serious Bleeding (Requiring Blood Transfusion)
- Death (Due to aforementioned injuries)
- Other

* How many days were spent in the Hospital?
Please enter a number from 1 to 60.

* Based on your responses, you may qualify for compensation! Please provide a brief description of the Xarelto side effects.

Your evaluation is almost complete! You may be entitled to compensation, but time is running out! Our law firm is standing by and are ready to evaluate your claim immediately. In order to receive compensation your claim needs to be voice verified, so please provide your best contact number.
First Name
Last Name
Email*
Phone Number (your best contact number please)*
Address*
Street Address City State ZIP Code
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Zapier Integration for Case Evaluation System

Xarelto Internal Bleeding Free Case Evaluation

Step 1 of 7