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First Name

Last Name

Email Address

Phone Number

Cell Phone Number

Street Address

City

State Choose State ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

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Date of birth of injured person (mm/dd/yyyy):

Date you were prescribed Avandia (mm/dd/yyyy):

Dates Avandia (rosiglitazone) was used (mm/dd/yyyy)

Was a heart attack suffered while taking Avandia? Yes No

If yes, indicate date of heart attack:

Please further describe injuries from Avandia:

Please describe Avandia related problems:

Other Comments:

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