Submit Your Nexium Case

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Nexium Intake Form

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  First Name *
  
  
  
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  Middle
  
  
  
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  Last Name *
  
  
  
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  Date of Birth *
  
  
  
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  How did you hear about us? *
  
  
  

  Google, Craigslist, Facebook, Twitter, Other (please describe)
  
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  Email *
  
  
  
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  Phone *
  
  
  
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  Alternate Phone *
  
  
  
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  Street Address *
  
  
  
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  City *
  
  
  
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  State *
  
  
  
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  Zip Code *
  
  
  
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  Date you first used Nexium *
  
  
  
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  Date you last used Nexium *
  
  
  
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  Did you sustain fractures to any bones after taking Nexium? ("Yes" or "No") *
  
  
  
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  List bones fractured after using Nexium
  
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  Name, address, telephone of Doctor who prescribed Nexium
  
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  List all illnesses prior to taking Nexium
  
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  Did you sustain fractures to any bones prior to taking Nexium? ("Yes" or "No") *
  
  
  
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  List bones fractured prior to taking Nexium and the date of each fracture
  
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  List name, address and telephone of all health care providers you have had in the past 10 years
  
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