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?

Did side effects from Permax (Pergolide) include:
Valve Damage
Valve Leakage
Valvulopathy
Mitral Valve Regurgitation
Aortic Valve Regurgitation
Valve Replacement

Date the above injury occurred:

If you had an echocardiogram, what was the result?

Other Info:

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