Avandia

Name:

E-mail:

Phone:

Address:

City:

State:

Zip code:

On whoes behalf are you inquiring?

Is this person deceased?

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

What date did you begin and end using Avandia?

What was the dosage and frequency that Avandia was taken?

Please list any side effects of Avandia that have been experienced:

When did you seek medical help for the side effects listed?