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First Name*:
Last Name*:
Year Of Birth:
Phone Number*:
Cell/Work Number:
Email Address*:
Address*:
City*:
State*:  Zip*:
How long have you been taking Vioxx?
Have you ever been hospitalizated or had surgery related to taking Vioxx? Yes No

Please select the drug(s) you've taken:

Vioxx (Refocoxib)
Bextra
Celebrex
Heart Attack? Yes No
Date:
Stroke? Yes No
Date:
Diagnosis of Stevens-Johnson Syndrome? Yes No
Date:
Were you taking the drug Vioxx/Bextra/Celebrex at the time you were diagnosed with your sroke, heart attack or Stevens-Johnson Syndrome? Yes No
Were you admitted to the hospital for your sroke, heart attack or Stevens-Johnson Syndrome? Yes No
 
 
 

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