Parker, Waichman, Alonso LLP

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
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Zip Code

Please provide the best method and times to contact you:

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

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

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

Name(s) of all antidepressants taken:

Age of patient when antidepressant(s) prescribed:

What condition was this medication prescribed to treat?

Did patient become violent while taking antidepressant(s)?
Yes
No

Was suicide attempted after taking antidepressant(s)?
Yes
No

Did attempted suicide result in death?
Yes
No

Was hospitalization or institutionalization required after taking antidepressant(s)?
Yes
No

If you have stopped taking Effexor, or have tried to stop taking Effexor, have you experienced withdrawal side effects?
Yes
No

Please further describe side effects:

Other Info:

No Yes, I agree to the Parker Waichman Alonso LLP disclaimers.Click here to review all.

Yes, I would like to receive the Parker Waichman Alonso LLP monthly newsletter, InjuryAlert.