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

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

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Apartment/Suite

City

State
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Zip Code

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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):

Has Rhabdomyolysis been diagnosed?
Yes
No

If yes, when was Rhabdomyolysis diagnosed?

Please further describe side effects:

Other Info:

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