* First Name
* Last Name
* Email
* Phone
Cell Phone
Date of Birth of Person Using Yaz, Yasmin, or Ocella (mm-dd-yyyy)
Date Started Using Yaz, Yasmin, or Ocella (mm-dd-yyyy)
Date Stopped Using Yaz, Yasmin, or Ocella (mm-dd-yyyy)
Date-of-Injury (mm-dd-yyyy):
Did you experience any of the following complications during or after using Yaz, Yasmin, or OcellaBlood ClotsDeep Vein ThrombosisPulmonary EmbolismHeart AttackStrokeDeath
Injury Description
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