Paxil Case Inquiry Form

* denotes required fields
Personal Information
* Name
* Address
City
State
Zip Code
Daytime Phone Number
Evening Phone
Mobile Phone
* E-mail Address
   
Paxil Questions
Date Began Taking Paxil
 
Date Stopped Taking Paxil
 
Reason for Which You Took Paxil
 
Reason for Stopping
 
Total Duration of Use
 
Dosage
 
U.S. State Where Paxil Was Prescribed
 
Injury Information
Did You Take Paxil During Pregnancy?
 
  Yes
  No
How Many Months Into Pregnancy Did You Take Paxil?
 
Date of Birth of Child
 
Did Your Child Have Any Birth Defects or Injuries?
 
  Yes
  No
If Yes, Please Describe
 
Did You And/Or Your Child Have Any Other Injuries You Believe Might Be Caused by Taking Paxil?
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.