Required Items Marked With "*"

Name*:

Street Address*:Apt. / Building Number:

City*:

State*:

Zip Code*:

E-Mail Address*:

Home Phone*:
- - Work Phone:
- - Cellular Phone:
- - Gender:

Date of Birth :

Work Status:

Best Way To Contact You::

Best Time To Contact You:

When Did You Start Taking Crestor?:

When Did You Stop Taking Crestor?:

What Side Effects Have You Experienced?:

Where Any Of The Side Effects Experienced Before Taking Crestor?:

Whom Are You Inquiring On Behalf Of?

Is The Person Deceased?:

If Deceased What Was The Cause Of Death ?

List The Names Of Any Doctors Who Prescribed Crestor:

How Did You Learn About Crestor?:

Why Was Crestor Prescribed?:

What Did The Doctor Tell You About Crestor Side Effects?:

Where You Given Any Printed Materials By Any Doctors?:

Where There Any Medications Taken With Crestor?:

If So Please List Them Here:

Have You Developed Any Serious Medical Conditions Since Taking Crestor?:

Yes No If So Please List Them Here:

When Were You Diagnosed?*:

Is There A Family History of Rhabdomyolosis?:

How Did You Hear About Us?:

If You Found Us Through A Search Engine Which One Did You Use?:

What Search Term Did You Use?:

Comments:

Would You Like To Arrange A Personal Interview?