Klein | Frank, P.C.

Phone: 303-448-8884
Fax: 303-861-2449

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Free Case Evaluation Form

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Free Case Evaluation

* denotes required fields
First Name* Last Name*
Email Address* Re-Enter Email Address*
Home Phone
(include area code)*
Cell or Alt Phone
Street Address* Apt
City*
State*
Zip Code*



Have you been diagnosed with nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD)?
Yes No Not Sure


Have you been diagnosed with kidney disease?
Yes No Not Sure


Are you on dialysis? Yes No


Are you currently represented by an attorney for any type of case?
Yes No Not Sure


Are you the injured person? If not, please state the name of the injured person and their relationship to you.
Yes No
Name Relationship


If the injured person has died, please answer the following:
Cause of death: Date of death:


Please briefly summarize the nature of your complaint.


Have you ever had any of the following?(Check all that apply) Approximately when did you have an MRI or MRA test done? (Check all that apply)
2008
2007
2006
2005 or earlier
Not sure
I have never had a MRI or MRA


Did they inject a dye into you before or during the MRI or MRA?
Yes No Not Sure


Since the MRI or MRA, have you experienced any of the following?
Swelling, tightening, or thickening of the skin
Skin lesions (patches, bumps or blisters)
Burning, itching or severe sharp pain in affected areas
Changes in skin texture (feeling "woody" or like orange peel)
Difficulty extending arms or legs
Muscle weakness
Deep bone pain in hips or ribs
Swelling of hands and feet
Unexplained high blood pressure
Other serious side effects
If other, please describe:


How did you find our website? If Other:


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