Semaglutide Claim Application

First Name

Last Name

Phone Number

Address

City

State

Zip

Have you been diagnosed with one of the following?

Gastroparesis (Stomach Paralysis)

Gastric Obstruction

Diagnosis date

Current age

Did you take any of the following products?

Ozempic

Wegovy

Rybelsus

Did your injury require ER Visit or Hospital Admission?

Yes No

Message

I expressly give consent to Environmental Litigation Group P.C. to contact me using email, SMS, phone calls, and pre-recorded messages at any phone number I provide, even if the number is a wireless number or on any federal or state do-not-call list. I understand calls may be placed using automated technology and that I am not required to submit this form for any reason.

I declare under penalty of perjury that all information provided on this form is true and correct to the best of my knowledge.

Disclaimer: The use of the Internet, this website form, or email as means of contacting this firm or any individual attorney of this firm will not establish an attorney‐client relationship, thus do not use a website form or email to submit confidential or time‐sensitive information. Whether you are a potential or existing client of the firm, ELG cannot represent you on any new matter until the firm has made a determination that there is no conflict of interest and that it is willing and otherwise able to accept the new engagement. Unless and until (a) ELG has informed you it is willing and able to accept your new matter and (b) you have signed a retainer agreement provided by ELG outlining the terms of the engagement, do not send the firm any information or documents that you consider private or confidential.