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case or answers to any questions you might have.
* required
* Name:
Any other name you may have
used while taking the patch:
Name If Not Same As Injured:
* Address:
* City:
* State:
* Zip:
* Home Phone:
* Work Phone:
* Alternate Phone:
* Email:
* Verify Email:
Spouse:
Usage Information:
Have you used a Fentanyl Pain Patch in the past?:
Yes
No
If YES, check appropriate boxes that apply:
Duragesic®
Abrika
Actavis
Mylan
Sandoz
Don't know?
When did you use your Fentanyl Pain Patch?:
Start Date:
Stop Date:
Name of Doctor Who Prescribed Fentanyl Pain Patch:
Doctor Name:
Doctor Address:
Doctor Phone Number:
Injury Information
Have you experienced trouble with breathing while on the patch?
Yes
No
Have you experienced a slow heartbeat while on the patch?
Yes
No
Have you experienced severe sleepiness while on the patch?
Yes
No
Have you experienced cold, clammy skin while on the patch?
Yes
No
Have you experienced trouble with walking or talking while on the patch?
Yes
No
Have you experienced feeling faint, dizzy, or confused while on the patch?
Yes
No
Were you hospitalized from using a Fentanyl Pain Patch?
Yes
No
If YES, Name, Address and Phone Number of Hospital:
Hospital Name:
Hospital Address:
Hospital Phone Number:
Did you seek medical attention for your injury / condition?
Yes
No
If YES, Name, Address and Phone of Facility where treatment was sought:
Facility Name:
Facility Address:
Facility Phone Number:
Are you unable work as a result of your injury / condition?
Yes
No
Are you permanently disabled?
Yes
No
What is the status of your injury / condition now:
Are you on medication or still treating it?
Yes
No
Please describe (what medication, what type of treatment, etc.):
Additional Comments:
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