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Defective Drugs Form

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Basic Information

 

Name

 

Email

 

Phone

 

State of Residence AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Other

 

DOB

 

Details About Injury

 

Drug Complained of: Choose Option Accutane Arava Avelox Baycol Celebrex Cipro Creatine DES (Diethylstilbestrol) Ephedrine (Ma Huang) Fen Phen Floxin Gardasil Influenza (Flu) Vaccine Levaquin Lotronex Lymerix Meridia MMR Vaccine Neurontin Paxil Permax Phenylpropanolamine (PPA) Premarin Premphase Prempro Propulsid Prozac Raxar Redux Rezulin Seroquel Serzone Tequin Thimerosal Trovan Vioxx Zoloft Zyprexa Other

 

When Did You Take This Drug?

 

Describe Your Injury

 

Are you human?