Fentanyl Patch

Name:

E-mail:

Phone:

Address:

City:

State:

Zip code:

On whose behalf are you inquring?

Is this person deceased?

What was the first and last date that the Fentanyl Patch was used?

Please list the side effects of the Fentanyl Patch that were experienced:

At what point did you seek medical assistance for these symptoms?

Are there any other details that you would like to share about this case?