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Medication, Drugs, Medical Devices Consultation

Medication, Drugs, Medical Devices Consultation

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  • Please provide the name of the device used or the drug or medication that was used or ingested.

  • What symptoms or injuries resulted? *

    Please list all the symptoms that resulted after use of the device or ingestion / application of the drug or medication.

  • Approximately what date did this matter first occur? * / /
    Pick a date.

    When did you start using the product, drug or medication?

  • What is the age of the person who has suffered the injury or problem?

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  • Contact Information (only with regard to this matter)

    Contact Information (only with regard to this matter)

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