Yaz Claim or Yasmin Claim | Legal Settlement Claims Office

Please provide us with the following information so our firm is able to properly evaluate your Yaz Claim or Yasmin Claim:

General Information:
Full Name: 

Maiden or Other Name: 

Parent/Guardian Name: 

Address (Street, Apt): 

Address (City, ST ZIP): 

Phone (Home):  Phone (Work): 
Phone (Cell):  E-Mail: 
SSN:  Date of Birth: 
Did you use one of the following:
Yaz:    Yes    No   Start Date:  End Date: 
Yasmin:    Yes    No   Start Date:  End Date: 

List names/addresses of Doctors who prescribed Yaz or Yasmin:
Doctor's Name: 

Address: 

City, ST ZIP: 

Telephone: 
Did you experience any of these events as a result of Yaz or Yasmin:
Deep Vein Thrombosis (blood clots in the legs):    Yes    No   Date: 
Blood Clots (other than in the legs):    Yes    No   Date: 
Pulmonary Embolism (blood clots in the lungs):    Yes    No   Date: 
Stroke:    Yes    No   Date: 
Death:    Yes    No   Date: 

Other medications taken while taking Yaz or Yasmin: 
Prior to taking Yaz or Yasmin, were you diagnosed with any serious medical conditions?
Prior Medical Conditions:    Yes    No   
If yes, please describe: 


Prior to taking Yaz or Yasmin, did you experience any type of blood clotting?
Prior Blood Clotting:    Yes    No   
If yes, please describe: 


If so, please list the names and addresses of Doctors & Hospitals from whom you received treatment for those conditions:
Doctor's Name: 

Address: 

Telephone: 
Hospital's Name: 

Address: 

Telephone: 
During the time you were taking Yaz or Yasmin, did you smoke?
Smoked During Yaz or Yasmin:    Yes    No   
Have you ever smoked?
Smoked Ever:    Yes    No   
If yes, when: 
List names and addresses of all Clinics or Hospitals where you were treated for Yaz or Yasmin-related injuries:
Hospital/Clinic Name: 

Address: 

Telephone: 
Type of Treatment: 

Dates of Treatment: 

List the names and addresses of the Pharmacies where Yaz or Yasmin were purchased:
Pharmacy Name: 

Address: 

Telephone: 
If Private Health Insurance or Medicaid/Medicare paid for the medical care and treatment you received as a result of your use of Yaz or Yasmin, please provide the following insurance information from your insurance card:
Insurance Co. Name: 

Policy Holder Name: 

Group Number: 

ID Number: 

Mailing Address: 

Telephone: 

Awards & Recognition

Gilman Law LLP and its attorneys have been recognized by the leading legal publications and are listed in:


Avvo Rating
Life Member, Multi-Million Dollar Advocates Forum
Life Member, Million Dollar Advocates Forum
Super Lawyers
Lexis Nexis
LawDragon
Association of Trial Lawyers of America
Massachusetts Association of Woman's Lawyers
American Association of Justice: Leaders Forum
American Bar Association and Member of the ABA Antitrust and Litigation Sections and Forum on Franchising and Litigation Section
Public Investors Arbitration Bar Association