Klein Lyons | H.R.T (Hormone Replacement Therapy)

Do You Qualify?

First Name:		Last Name:
Mailing Address:		City:
Province:		Postal Code:
Home Phone:		Work Phone:
Email:
If you are unable to provide an email address, please phone us at 604-874-7171

Medical Details
What H.R.T. drugs did you take?
Premarin (Alone):	Yes No
Premplus (Alone):	Yes No
Premarin & Progestin (In combination):	Yes No

Other brands of H.R.T. ?

Yes No

Do you want information only and have no current health problems?

Yes No

I expected you to be quick but that was amazing! Your law firm exceeded my expectations of service and client care. I will recommend your firm to anyone.
— Nicole Sharma

For more information

Shauna Tucker

604.874.7171

stucker@kleinlyons.com

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If yes, which brands of H.R.T.:
Dates of use:	to
Name of prescribing doctor:
Address of Doctor:
Phone:
Are you still seeing this Doctor?	Yes No

Have you been diagnosed with any of the following subsequent to your H.R.T.?
Lobular Breast Cancer:	Yes No
Ovarian Cancer:	Yes No
Ductal Breast Cancer (Hormone Positive):	Yes No
Lupus:	Yes No

Dementia	Yes No
Gall Bladder Disease	Yes No
I.B.S. (Irritable Bowel Syndrome)	Yes No
Arthritis:	Yes No
Cardio Vascular Events from blood clots:
Stroke:	Yes No
Heart attack:	Yes No
Pulmonary embolism:	Yes No
Other illness you feel may be related to H.R.T.:
Details:
Date of diagnosis:

If not, name of current G.P.:
Address of G.P.:

Do You Qualify?

Medical Details

For more information