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Breaking Accutane News

Breaking Accutane News

Accutane Inquiry

PERSONAL INFORMATION

First Name: *

Last Name: *

E-mail Address: *

Phone:

() - ext.

Address:

City:

State:

Zipcode:

ACCUTANE INFORMATION

Name of Injured Person

Do you suffer from the following injuries: (please check all that apply)

Lupus
Auto-Immune Disorder
Ischemic Bowel
Ulcerative Colitis
Crhon's Disease
Irritable Bowel Syndrome

Ischemic Colitis
Colostomy
Birth Defects
Severe Violence
Attempted Suicide

Was there an attempted suicide?

Yes
No

If so, enter the date:

Date of birth of injured person:

Date of death? (if applicable)

Cause of death? (if applicable)

Was Accutane listed as part of the cause of death?

Yes
No

When did they (you) take Accutane? Start Date:

End Date

Briefly Describe the Experience with Accutane *:

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