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Accutane Form

Accutane Form

NOTE: An Asterisk (*) Indicates REQUIRED Information.

*Full Name:

Company:

Home Address:

City:

State:

Zip:

Telephone Number:

  

Facsimile:

  

*E-mail Address:

When was the drug taken?:

When did you notice side effects/symptoms?:

When did you learn that Accutane may have caused your condition(s)?:

 Ex: mm/dd/yy

Describe your symptoms:
 

 

Additional Comments:


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