Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
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Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

What condition was this medication prescribed to treat?

What dosage were you prescribed daily?

Have any of the following side effects occurred? (Please check all that apply.)
Heart Attack
Stroke
Blood Clots
Kidney Problems
Other
Death

Please further describe side effects:

Other Info:

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