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First Name
Last Name
Email Address
Phone Number
Cell Phone Number
Street Address
Apartment/Suite
City
State
Zip Code
Date of birth of injured person (mm-dd-yyyy):
Date you started taking Zyprexa
(mm-dd-yyyy):
Date you stopped taking Zyprexa
(mm-dd-yyyy):
Were you diagnosed with diabetes before taking Zyprexa?
Yes
No
Were you diagnosed with diabetes after taking Zyprexa?
Yes
No
Please describe the side effects you experienced:
Other information:
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NEW YORK
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Uniondale, NY 11556
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Boston, MA 02109
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