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
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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?
What dosage were you prescribed daily?
Did side effects from Mobic include any of the following?Heart AttackStrokeDeath
Date the medical problem(s) first occurred:
Please further describe side effects:
Other Info:
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