Fort Lauderdale, Florida Accident Attorney :: Accutane Questionnaire

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Accutane Questionnaire

Fill out the form below if you have taken Accutane®, Amnesteem® , Claravis® or Sotret® and you have suffered gastro-intestinal problems, including inflammatory bowel diseases (IBD) such as Ulcerative Colitis and Crohn’s Disease, within 5 years of using Accutane or one of its generic substitutes named above.

Contact Information: Name:* Email:* Phone Number:* Alternate Phone Number: (Optional) Address: City: State: ZIP: What is the best number to reach you? Date of Birth: Have you taken Accutane, Amnesteem®, Claravis® or Sotret®? IF yes, when did you start using it? For what condition was it prescribed? For how long did you use it? Have you been diagnosed with IBS, IBD, Crohn's disease, or ulcerative colitis within 5 years of taking Accutane? When was the above medical condition diagnosed? Please describe your condition:

Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.