Your Potential Suboxone Claim

We handle cases that change lives.

Please fill out the form below so the Peiffer Wolf team can review your potential claim.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Alternate Mailing Address:

Cell Phone Number:*

Cell Phone Provider:*

Home Phone Number:*

Best Days/Times to Contact You:*

Email*

Date of Birth:*

Social Media Handles:*

Emergency Contact Name:*

Emergency Contact's relationship to child (parent, spouse, friend, etc.)*

Emergency Contact Phone Number:*

Emergency contact email:*

SUBOXONE USE

Did you use brand name Suboxone?*

If no, which brand(s) of Suboxone did you use?*

Did you use Suboxone Film as prescribed for more than 6 months?*

List other similar drug (Subutex, Zubsolv) usage, if any:*

Have you ever used Methamphetamine?*

Why were you prescribed Suboxone?*

If for opioid addiction, how did the addiction begin? (ex: prescription for injury, recreational use?)*

When did you start using Suboxone?*

Do you still use Suboxone? If not, when did you stop?*

Did you use the Film, Dissolvable Tablet, or both:*

What form(s) and dosage(s) of Suboxone did/do you use (note if changed over time - how often did/do you use Suboxone? How many times a day?):*

Did you ever use unprescribed Suboxone:*

If yes, before or after having prescription for Suboxone?*

Please list your Prescriber/Physician:*

Prescriber Address:*

Prescriber Phone Number:*

Type of Care (Select One):*

DAMAGES AND SIDE EFFECTS

What date did you first notice dental damage? (year only will suffice):*

Did a medical or dental professional notify you that Suboxone was impacting your dental health:*

If yes, when were you first notified by a professional that Suboxone was impacting your dental health:*

What type of dental damage have you experienced? (Check All that Apply)*

Tooth Damage

Tooth Cracking

Cavities

Gum Damage

Tooth Loss

Tooth Erosion/Crumbling

Increased sensitivity

Tongue damage

Number of teeth lost:*

Number of teeth Crumbling:*

Number of teeth with pain:*

Number of teeth with cavities:*

Did you ever fall asleep with Suboxone under tongue / in mouth?*

Did you ever brush teeth within one hour after Suboxone use?*

Describe any dental damage after taking Suboxone not covered in the questions above:*

PRE-USE DENTAL CARE

Describe any dental damage you experienced prior to being prescribed Suboxone (Cavities, periodontal disease, lost teeth, etc.):*

Dental Care Provider Pre-Suboxone Use-if none, please mark "N/A"

Dental Office Name:*

Address:*

Dentist's Phone*

Please list types of dental care treatments received prior to Suboxone use, with date of treatment, if known:

Routine cleaning / care:*

Fillings:*

Extractions / surgery:*

POST SUBOXONE USE DENTAL CARE

Dental Care Provider Post-Suboxone Use:*

Dental Office Name:*

Address:*

Phone*

Please list types of dental care treatments received after Suboxone use, with date of treatment, if known:

Routine cleaning / care:*

Fillings:*

Extractions / surgery:*

Suboxone Providers

Please list your Prescriber/Physician

1. Prescriber Name:*

Prescriber Address:*

Prescriber Phone Number:*

Type of Provider:*

2. Prescriber Name:

Prescriber Address:

Prescriber Phone Number:

Type of Provider:

3. Prescriber Name:

Prescriber Address:

Prescriber Phone Number:

Type of Provider:

Pharmacies

1. Pharmacy Name:*

Pharmacy Address:*

Pharmacy Phone Number:*

From date:*

To date:*

2. Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

From date:

To date:

3. Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

From date:

To date:

4. Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

From date:

To date:

Victim of Investment Fraud or Broker Misconduct?

Contact us

Suboxone Client Questionnaire

We handle cases that change lives.

SUBOXONE USE

DAMAGES AND SIDE EFFECTS

PRE-USE DENTAL CARE

Dental Care Provider Pre-Suboxone Use-if none, please mark "N/A"

POST SUBOXONE USE DENTAL CARE

Suboxone Providers

Pharmacies

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Contact us

Suboxone Client Questionnaire

We handle cases that change lives.

SUBOXONE USE

DAMAGES AND SIDE EFFECTS

PRE-USE DENTAL CARE

Dental Care Provider Pre-Suboxone Use-if none, please mark "N/A"

POST SUBOXONE USE DENTAL CARE

Suboxone Providers

Pharmacies

Victim of Investment Fraud or Broker Misconduct?