Accutane

Name:

E-mail:

Telephone:

Address:

City:

State

Zipcode:

For who are you inquring:

Is the person deceased?

If the person is deceased please list the cause stated on the death certificate:

Please list the dates accutane was used:

Please list any side effects of Accutane that you have been diagnosed with:

Pelase select the brand of Accutane used

When did you seek medical attention for the side effects you listed above?

What state where you living in when you were diagnosed with the symptoms above?

Please list the date you realized that Accutane was the cause of your problems:

How did you find out that Accutane was the cause of your problems?

Please list any additional information you feel may be relevant to your potential Accutane case: