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

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* Last Name

* Email Address

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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):

Have you been diagnosed with NAION (nonarteritic ischemic optic neuropathy)?
Yes
No

Please describe any side effects:

Other Info:

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