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

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:

Phone

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

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

window.tgpQueue.add('tgpli-681088e6ae653')<img class="aligncenter size-full wp-image-25154" src="https://peifferwolf.com/wp-content/uploads/2021/06/scale.png" alt="" width="50" height="40" />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

Victim of Investment Fraud or Broker Misconduct?