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Contact Information:
*Title:
*First Name:
MI:
*Last Name:
*E-mail Address:
*Retype = E-mail:
Home Phone:
- -
Mobile Phone: - -
Work Phone: - - ext.
  *Provide at least 1 phone number.
Street = Address:
Apt/Suite:
City:
State/Zip: /
 
What is the best way to reach you?
Please provide the best place, time and method for contacting you.
 
Additional Contact Information:
Use this area to add country codes, foreign addresses, special instructions, etc.
Injured Person Information:
Date of Birth:
Whom are you inquiring on behalf of?
If you are NOT inquiring on your own behalf, what is your relationship?
Is the person deceased? Yes No

If deceased, the cause of death
as stated on the death certificate: 

Date of Death:
Was there an autopsy performed? Yes  No  n/a
Case Information :

During what period of time was Vioxx prescribed?
Start End

Why was Vioxx prescribed?

What dosage of Vioxx were you prescribed daily? (i.e. 25mg, 50mg, 75 mg)


List names/addresses of any doctors who prescribed Vioxx:


Did effects from Vioxx include:

Heart Attack Yes No
Stroke Yes No
Blood Clots Yes No
Deep Vein Thrombosis Yes No
Pulmonary Embolism Yes No
Death Yes No



Other medical problems since Vioxx usage:


Other Information:


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