Zapier Integration Page – National Injury Help

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This field is for validation purposes and should be left unchanged.
* 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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*Agreements
- By leaving this box checked, I agree that the information viewed is advertising and that you agree to receive future advertisements from Hood National Law Group and/or its partners.
- I agree that submitting this form and the information contained therein does not establish an attorney client relationship.
- I agree that the information submitted will be reviewed by more than one attorney and/or law firm.
- I agree that the information that I will receive in response to the above question is general information and I will not be charged for the information. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.
- I understand that I may receive, and am willing to accept, a telephone call from a lawyer/law firm to discuss this submission.
By clicking SUBMIT you agree to be contacted by National Injury Help via phone call, email, or text.
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Zapier Integration for Case Evaluation System

Xarelto Internal Bleeding Free Case Evaluation

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