Drug Information |
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Date Started Permax |
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Date Ended Permax |
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Dosage of Permax You Were Prescribed |
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Heart Valve Damage
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List any problems you developed while you were taking Permax: |
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When did you first suspect that you had adverse effects as a result of taking Permax? |
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Did a doctor ever tell you that you were injured as a result of taking Permax:
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If so, when? |
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YOUR CONTACT
INFORMATION
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First Name: |
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Last Name: |
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Address: |
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City: |
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State: |
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Zipcode: |
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E-mail Address: |
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Phone
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() - ext.
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