WP E-Signature by Approve Me - Sign Documents Using WordPress -

Suboxone Dental Damage Lawsuit

IMPORTANT NOTICE:

Please read before filling out these documents:

Please fill out these forms for the Suboxone Dental Damage Lawsuit. Please note: There are two forms to choose from, depending on the state you live in. If you do NOT reside in one of the states below, fill out the forms on the pages below.

If you reside in one of the states listed below, you need to click on this link for the correct forms:

https://theclassactionnews.com/dolman-suboxone-lawsuit/

KENTUCKY

LOUISIANA

PUERTO RICO

TENNESSEE

ALABAMA

ARKANSAS

ARIZONA

CALIFORANIA

COLORADO

DELEWARE

FLORIDA

GEORGIA

HAWAII

IDAHO

ILLINOIS

INDIANA

IOWA

KANSAS

NEVADA

NEW JERSEY

OKLAHOMA

OHIO

OREGON

PENNSYLVANIA

TEXAS

UTAH

VIRGINIA

WEST VIRGINIA

Name and Contact Information

Name

Address

City

State

Zip

Alternate mailing address such as a PO box

Other back up email

Phone

SSN (for medical records) If you do not want to provide it, tell us you will provide it later

Social Media profile / handle name (we recommend this as a back up way to notify you if there is a payment to you)

Best Contact Time / contact instructions

Secondary/Emergency Contact Name

Emergency Email

Emergency Phone

Suboxone Film Use

When did you start taking Suboxone FILM?

Dosage that you have been taking of the Suboxone FILM

Have you taken any other type of Suboxone such as the pill tablet?

Yes

If you took the Suboxone pill tablet, when did you start taking it?

If you took the Suboxone pill tablet, when did you stop taking it?

If you have not stopped taking the pill tablet please say “I’m still taking the pill tablet” here

How many times each day do / did you take the SUBOXONE TABLET?

How many times each day are you or were you taking the SUBOXONE FILM

When did you have the first signs of dental damage ?

What type of dental damage have you experienced?

Increase sensitivity

Cavities

Tooth loss

Tooth cracking

Tooth erosion

Tooth crumbling

Did you start taking Suboxone for pain management or opioid addiction?

Opioid addiction

Pain

Number of teeth lost

Number of teeth crumbling

Number of teeth with pain

Did you ever use methamphetamine?

Yes

Prescribing Doctor (include city and state):  
Name:

Pharmacy product was filled at, including city and state:

Pre-Use Suboxone Dental Care

BEFORE taking Suboxone, did you have cavities, periodontal disease or lost teeth ?

Cavities

Peirodontal Disease

Lost Teeth

Other please describe

None

If other dental damage, please describe

Dental Care Pre-Use Provider Information

Dental Office Name or Dentist Name (If you don't know, then state "I don't know")

Address (If you don't know then state "I don't know")

Phone

Start Treatment Date

End Treatment Date

Dental Care After Starting Suboxone (Post-Use)

What is the name of the dental office or dentist who gave you dental treatment after you started Suboxone?Provider Dental Office Name or Dentist Name

Address

Phone

Start Treatment Date

End Treatment Date

What types of treatment have you had during the time after you started Suboxone?

Routine cleaning / care

Cavities / Fillings

Extractions / Surgery

ATTORNEY-CLIENT CONTINGENCY FEE RETAINER AGREEMENT

Suboxone Film Product Liability Litigation

This Agreement is between you (“Client”) and Cooper Law Partners PLLC and The Law Offices of Jennifer Duffy APC ("Attorneys").

Scope of Representation. Client hires Attorneys to represent Client in investigating and, if appropriate, pursuing a potential claim for injuries and damages caused to Client by Suboxone Sublingual Film (the “Claims”). Attorneys shall have the right to withdraw and cancel this Agreement if they are unable or unwilling to undertake the representation for any reason. After investigating the potential claim, Attorneys shall have the right to withdraw and cancel this Agreement if they are unable or unwilling to undertake the representation. Attorneys agree to use their best effort and skill in pursuing this case but do not guarantee a specific result.

Authority of Attorneys. Client appoints Attorneys or its designees to perform any and all acts that in its judgment may be reasonable and necessary in the handling of the cause of action, including but not limited to hiring investigators or expert witnesses and obtaining medical records. Client agrees that Attorneys may associate additional lawyers/firms to assist in this matter and Client agrees to the sharing of fees between lawyers upon notice to Client. Association of other lawyers or law firms will not increase the amount of the attorney fee due to Attorneys upon successful resolution of the claim.

Contingency Fee. Client will only owe a legal fee if Attorneys collect compensation on Client’s behalf. If Attorneys are unable to collect anything on Client’s behalf, Client will owe nothing. If Attorneys obtain settlement or judgment for Client, Client will pay to Attorneys forty percent (40%) of the gross recovery, before reimbursement of expenses. The Attorneys’ fees shall be shared as follows: Cooper Law Partners PLLC shall receive 50% and The Law Offices of Jennifer Duffy APC shall receive 50%. The fee set forth in this Agreement is not set by law. Attorneys’ compensation will not exceed any limits on compensation imposed by law.

California Fee Terms. In consideration for the services rendered by Attorneys, Client hereby assigns and transfers to Attorneys, as a lien, undivided interest in the subject matter of the claim(s) or suit in the amount of 40% of the gross recovery of claim(s). The Attorneys’ fees are calculated and deducted from the gross recovery before the deduction of expenses.

Should local counsel, appellate counsel, settlement counsel, or other affiliated counsel be needed or used for litigation purposes only, such fees will be deducted from gross attorneys’ fees prior to split of Attorneys’ fees between Attorneys. Attorneys shall have sole authority to add additional counsel to further claim(s). The Law Offices of Jennifer Duffy, APC retains the option, solely at the Law Offices of Jennifer Duffy, APC’s election, to defer or structure all or a part of its share of the Attorneys’ fees at the time of settlement, and to take all or a part of its share of the Attorneys’ fees as an “up front” cash payment at the time of settlement and/or as periodic payments, or a combination thereof, regardless of the manner in which the Client's recovery is paid.

Client hereby acknowledges that Jennifer Duffy, an attorney, will be receiving a share of the fees from the Attorneys’ fees paid in this case (providing that case resolves favorably for Client), from Cooper Law Partners PLLC. That fee will be 50% of the Attorneys’ fees. Cooper Law Partners PLLC’s agreement to pay a fee will not increase the fee payable under this contract. Cooper Law Partners PLLC alone has the obligation to pay the fee from the fee(s) stated in this paragraph. Client, pursuant to the provisions of Rule 1.5.1 of the Rules of Professional Conduct of the State Bar of California, hereby consents to the payment of a shared fee as set forth in this paragraph.

Case Expenses. Attorneys will advance all expenses incurred on Client’s behalf during the term of investigation and litigation. Examples of expenses include, but are not limited to, the following: filing and service fees; costs for reports and records; costs for third-party record reviews and summaries; expert witness costs; cost for investigative services; reasonable travel expenses (including air fare, ground transportation, lodging and meals); deposition expenses and court reporter fees; costs and fees associated with any necessary estate administration procedures; outside trial service providers; outside settlement support service providers; interest on costs advanced by Attorneys; costs associated with third-party case support service providers; the cost of probate; trial equipment rental and operation fees; preparation of exhibits and graphics; and copying, postage, shipping and courier expenses. Client understands and agrees that Attorneys may use non-lawyer third-party service providers to assist in the handling of Client’s case by providing case support services, including but not limited to: record retrieval, record review, enhanced communication and reporting, client outreach, and settlement support. Client understands and agrees that such service providers are not engaged in the practice of law and will not provide legal services or legal advice to Client or Attorneys. Client authorizes Attorneys to use their best judgment in selecting such service providers. In the event of a recovery, Client agrees to reimburse Attorneys for all such costs and expenses from Client’s share of any money recovered by settlement or judgment. Client understands that Attorneys may represent multiple individuals in this case and may incur shared costs necessary to prosecute all of those individuals’ claims.

When Attorneys represent more than one similarly situated claimant, each Client is entitled to pay ONLY his/her proportionate share of such costs that are spent for the mutual benefit of all clients. When more than one client’s case benefits from such expenditure, said common costs shall be shared by each Client and deducted from the Client’s recovery in an equitable and proportionate manner.

Client’s Duties. Client agrees to cooperate fully with Attorneys, disclose all relevant facts and promptly advise Attorneys of any change in address or telephone number, and to promptly comply with all reasonable requests of Attorneys on all matters related to this contract. Client agrees to be available for consultation, investigation, deposition, and trial preparation, and to do necessary work as Attorneys direct and do nothing to impair the value of the case. Client understands that Client now has a legal obligation to preserve all documents and tangible items relating to this action. “Documents” for purposes of anticipated discovery in this case includes not only written or printed materials or communications, but also tape, audio, or video recordings; emails, instant messages, and text messages; and all other forms of electronically stored or transmitted materials, whether on computer, smartphone, tablet, or other device. To the extent Client has or acquires any of the above-described documents or tangible items, Client shall make sure all necessary steps are taken to preserve them even if they may be protected from discovery by a privilege (e.g., client-attorneys privilege).

If Client fails to comply with any of the responsibilities contained in this Section, Attorneys may dismiss any claim that it may have filed on my behalf, or in Attorneys’ discretion, withdraw from representing Client, and Client agrees to not oppose any such motion to withdraw filed in a legal proceeding.

Multiple Clients. Client understands and agrees that Attorneys may represent more than one client in this matter and that the following aspects of joint representation have been disclosed: (1) the Client might gain or lose some advantages if represented by separate counsel; (2) Attorneys cannot serve as an advocate for one client against another client; (3) Attorneys must deal impartially with every client; (4) information received by Attorneys from or on behalf of any jointly represented client concerning the matter may not be confidential or privileged as between the jointly-represented clients; and (5) if a conflict arises between clients, Attorneys might not be able to continue representing any of the clients involved. Client consents to Attorneys representing more than one client in this matter.

Conflict and Settlement. Client understands that Client is one of multiple plaintiffs being represented by Attorneys. Client consents to such representation and waives any potential conflict that might arise from such representation. For example, Client recognizes and agrees that the parties may reach a global settlement of Claims for multiple clients, in which a fixed settlement amount is divided between all of Attorneys’ clients. Client will have the final decision whether to accept any proposed settlement. The decision to settle or resolve an individual case is exclusively held by Client. But Client agrees that he or she will not make a settlement demand or offer of settlement without the consent of Attorneys, and that Client will not unreasonably withhold consent to a settlement proposal which, in the judgment of the Attorneys, is fair and reasonable.

Termination of this Agreement. If this Agreement is terminated before the case is resolved, Client gives Attorneys a lien against any subsequent recovery in this case for Attorneys’ time and expenses. If an offer has been negotiated, Attorneys will have a lien upon any subsequent recovery equal to 40% of the offer, or an amount to compensate for time and expenses, whichever is greater. Client may terminate Attorneys’ representation of Client at any time by providing written notice to Attorneys at the address of their principal office. Attorneys may withdraw from representation of Client at any time if they determine prosecution of the claim is not practicable.

It is agreed and stipulated that neither the Attorneys, Client, any agent, employee, nor other representative may transfer or refer Client’s case or claims to another law firm without confirmation and consent of The Law Offices of Jennifer Duffy APC and Cooper Law Partners PLLC.

Limited Power of Attorney. Client hereby grants Attorneys a limited power of attorney to execute all documents and papers that Client would execute relating to the subject matter of the claim or cause of action. Client hereby grants Attorneys a limited power of attorney to endorse Client’s name to any checks or drafts received by Attorneys in settlement of any and all claims pursued by Attorneys on behalf of Client. Such settlement funds shall be placed in trust for Client’s benefit.

Power to Sign. Client hereby gives permission for Attorneys to sign documents on their behalf during and for this litigation only. Specifically, Attorneys can sign litigation documents, HIPAA authorizations, and HITECH letters, and any other letters related to patient access requests on behalf of Client. Attorneys are also authorized to sign Plaintiff Profile forms, Plaintiff Fact Sheets, and any legal instruments, pleadings, drafts, authorizations, claims, and papers as shall be reasonably necessary to commence, conduct and conclude this representation. Client authorizes the use of their signature including an image of their signature to complete requests for medical records as authorized by Attorneys.

Medical Liens. Client agrees that Attorneys may take all steps deemed advisable for the resolution of any medical insurer (including Medicare/Medicaid and private insurers), disability insurer, and/or workers’ compensation liens, including hiring separate experts/case workers who assist with resolving such reimbursement claims or liens. The expense of any such service shall be treated as a case expense and deducted from client’s net recovery and shall not be paid out of Attorneys’ contingent fee.

Appeal. Attorneys have the sole right to accept or reject any appeal. If an appeal is determined to be warranted by Attorneys, the contingent fee agreement herein will be subject to increase by a non-contingent hourly amount agreed to by Client and Attorneys, at that time.

Death. If Client dies before the claim covered by this Agreement is resolved, this Agreement is binding on and shall inure to the benefit of the Client’s heirs, death beneficiaries, and the personal representative of the Client’s estate. Attorneys are not experts in probate law, and if it is necessary to retain probate counsel, expenses for such counsel shall be borne by Client.

Timeliness of Claims / Statute of Limitations. Client’s claims must be brought within a limited time period, set by the statute of limitations or statute of repose, or Client’s legal rights can be lost or barred forever. Client understands that Attorneys will not file a case until all medical records are received to support a meritorious case. Client agrees that they will not hold Attorneys responsible for any claims lost due to the expiration of the statute of limitations. Client understands that evaluation of Client’s case may take several months or years after Attorneys receive this signed Agreement. Client acknowledges the importance of providing timely responses to Attorneys’ requests for documents and information, and Client accepts the risk that any delay on Client’s part may cause Client’s claims to be barred by the statutes of limitations or repose. If Attorneys determine that there is no basis to excuse the statute of limitations, Client understands and agrees that Attorneys may decline to file a civil lawsuit or voluntarily dismiss a filed lawsuit on Client’s behalf and may terminate the representation.

Medical Malpractice Claims Not Included. Client understands and agrees that Attorneys will not investigate and will not pursue a medical malpractice action or any other claim against Client’s doctor(s) or other healthcare provider. Client understands that any claim or lawsuit against Client’s doctor(s) and/or healthcare provider must be filed with the Court and served upon the doctor(s) within the lawful time limit (statute of limitations). Client further understands that if they desire to pursue a claim against their doctor, Client will need to retain other counsel, immediately, to investigate and possibly pursue such a claim.

Communicating by Text. Client provides Attorneys and their designees and agents express permission and authorization to send text messages and automated calls to the number or numbers Client provides to Attorneys or their agents during the intake process and thereafter. Client represents that he or she is the subscriber of those numbers and has the authority to give such consent. By executing this Agreement, Client authorizes Attorneys to deliver or cause to be delivered to Client calls using an automatic telephone dialing system or an artificial or prerecorded voice.

Arbitration. In the event of any dispute, controversy, or claim between Client and Attorneys (or their respective heirs, successors, assigns, or affiliates) arising out of, relating to, or in connection with Client’s engagement of Attorneys (any of the foregoing, a “dispute”), Client and Attorneys waive the right to seek remedies in court, including the right to a jury trial, and agree to submit said dispute exclusively to binding individual arbitration conducted by a single arbitrator subject to the rules of the American Arbitration Association (“AAA”). Client and Attorneys agree the arbitrator shall not order or allow consolidation or arbitration on a class wide or representative basis. The arbitrator shall not have the authority to decide any claims as a class, collective, or representative action. The seat of the arbitration will be in Washington, DC unless AAA determines that this location will impose undue hardship, in which case the location will be set by AAA. The parties will share the expense of arbitration equally, except that if Client represent that this would impose an undue hardship, Client will initially be responsible only for a filing fee equal to the amount that would be necessary to file Client’s claim in court. In that event, Attorneys will advance the remaining fees and expenses on Client’s behalf and the arbitrator will determine any additional amount Client can pay without sustaining undue hardship. Threshold issues of arbitrability shall be decided by the arbitrator, including the scope of and whether a controversy or claim arises out of or relates to this Agreement.

If any provision of this agreement shall be held to be invalid, illegal, unenforceable, or in conflict with the laws of any jurisdiction, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.

Confidentiality. It is in Client’s best interests to preserve the confidentiality of all communications between Client and Attorneys. If Client talks to anyone other than Attorneys or their staff, except for Client’s spouse, about discussions between Client and Attorneys or members their staff, Client risks the attorneys-client privilege and perhaps other privileges. Therefore, Attorneys advise Client to not talk to any third parties about any discussions you have had with anyone at Attorneys’ offices.

No Solicitation of Client. By signing and entering into this agreement, Client hereby affirms that Client’s case was not solicited by Attorneys, the agreement is not being entered into as a result of promises of money, no promises of a successful recovery have been made to Client, and Client has freely and voluntarily entered into this agreement.

Miscellaneous. Client understands that Client has the right to consult with an independent attorney of Client’s choice with respect to any and every aspect of this Attorneys Representation Agreement.

Client Signature:	Signature on following page	Date:	December 30, 2024
Client Printed Name:

Attorneys Signature:		Date:	December 30, 2024
Attorney Signature	On behalf of Cooper Law Partners PLLC	Date:	December 30, 2024
	On behalf of Law Offices of Jennifer Duffy APC

Torticity, LLC Patient Agreement

Patient Name:

This Torticity, LLC Patient Agreement (“Patient Agreement”) is a legal agreement between the patient named above (“you” or “Patient”) and Torticity, LLC (“Torticity”) that establishes the terms and conditions under which Torticity agrees to serve you.

Torticity is an information technology service provider that enables you and your Personal Representative(s) to use electronic means to collect, access, maintain, and share (collectively “Process”) your health information and medical records (the “Service”).

Definitions
1. Custodians are health care plans, insurers, health care clearinghouses, providers, and others who transmit Personal Health Information to Torticity with your consent.
2. Personal Information is information that identifies, relates to, describes, or could reasonably be linked, directly or indirectly, with you.
3. Personal Health Information is personal information relating to your past, present, or future health status sent by you or obtained from Custodians that Torticity may Process on your behalf.
4. Your Personal Representative is an individual who is authorized by law to consent to the collection, use, or disclosure of your Personal Health Information on your behalf.
Torticity agrees to Process and to facilitate access by you and your Personal Representative(s) to your Personal Health Information to provide the Service.
To allow Torticity to provide the service, Patient:
1. Authorizes Torticity to Process your Personal Health Information on your behalf and at your direction or the direction of your Personal Representative including, without limitation, your attorney;
2. Consents to Torticity’s Processing of Personal Information about you in accordance with the Torticity Consumer Privacy Policy, available at: https://www.torticity.com/privacy;
3. Consents to Torticity’s use of your signature including an image of your signature to complete requests for medical records as authorized by you or your Personal Representative including, without limitation, your attorney; and
4. Agrees to abide by all applicable Torticity policies including, without limitation, the Torticity Website General Terms and Conditions, available at: https://www.torticity.com/terms.

Signature Image (must be completely within box borders)

Image Signature on following page Initials on following page

I Agree

Signature: On Following Page Date: December 30, 2024

Name:

Relationship to Patient: Self

DESIGNATED AGENT AUTHORIZATION

To Whom it May Concern:

Client: (“Client”)

Law Firm: Cooper Law Partners LCCP (“Law Firm”)

I, Client, hereby affirm that I have retained Law Firm as my attorney. Until such time as this representation may terminate or I may otherwise revoke this authorization, I further affirm that Law Firm is my agent and “Legally Authorized Representative” for the purposes of requesting and obtaining my health care information from health care providers and for following up on such requests. This authorization satisfies, but is not limited to, the definition of Legally Authorized Representative set forth in state or federal law. I further authorize and direct Law Firm to use a record collection service, specifically including, without limitation, Torticity, LLC, as the law firm’s agent and my personal representative for the purposes of (1) obtaining records related to my treatment from health care providers, insurance companies, or any other entity; and (2) following up on such requests. I hereby authorize Law Firm and its agent to sign documents on my behalf for the duration of this representation only. Specifically, Law Firm and its agent, can sign litigation documents, HIPAA authorizations, HITECH letters, and any other letters related to patient access requests on my behalf.

Sincerely,

Signature on following page

Name:

By signing this document, I agree to the Designated Agent Authorization .

By signing this document, I agree I have read and agree to the ATTORNEY-CLIENT CONTINGENCY FEE RETAINER AGREEMENT.

By signing this document, I agree to the Torticity Patient Agreement

Client Initials:

I understand my initials are binding confirmation of my agreement to the Torticity Patient Agreement and they may use my initials to obtain dental or medical records on my behalf in addition to my signature.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

October 6, 2023 4:01 pm PST

Suboxone Dental Damage Lawsuit Uploaded by Law Offices of Jennifer Duffy - [email protected] IP 2603:8000:7301:e00c:b1e4:8d2d:f42:1a5