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Please Fill Out The Invokana Claim Form To Confirm Your Elgibility
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Spanish (Latin America)
1
Name
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First Name
Last Name
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2
Email Address
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example@example.com
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3
Phone Number
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Area Code
Phone Number
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4
Did you or a loved one take one of the following medications for treatment of diabetes?
*
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(Please check any that apply)
Invokana
Invokamet
Farxiga
Jardiance
Xigduo
Glyxambia
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5
Did the medication user suffer any of the following injuries within 15 days of last use of the medication?
*
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(Please check any that apply)
Amputation
Diabetic Ketoacidosis
Kidney Failure
Stroke
Bone Fracture
Death
Other
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6
Do you currently have an attorney representing you regarding this issue?
*
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Yes
No
Declined
No
Yes
No
Declined
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