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):

Which Bitter Orange products were used?

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

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

Have you taken the diet drug Meridia?
Yes
No

Approximate number of servings taken:
Select 1-20 20-50 50-80 80-120 More than 120

Products obtained from:
Select Gym Store Physician Personal trainer Mail order Internet Other

Have any of the following occurred? (Please check all that apply.)
Cardiac death
Hemorrhagic stroke
Heart attack
Seizures
Cardiac arrythmia

Please further describe side effects:

Other Info:

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