Step 1. Contact Information This form is confidential and HIPAA compliant First Name Last Name Phone Number E-mail Go back Next Medication (dosage) Is this a medical emergency? NO If you feel this is a medical emergency, please call 911 or go to your nearest urgent care or emergency room! Previous Next Side effect (please add as many details as possible) When did this side effect start? How long have you been having the side effect for? Previous Next Your Primary Provider? Select your provider Dana Markee Emily Ashley Ibrahim Farooque Azam Nsreen Jesri Michael Joanitis Tiffany Cooper Yulia Koba Antoniadou Steven Berry Clarito Villanueva Emiliano Baquir Kalpesh Bhavsar Sherwin Wong Wendi Sellers David Gueringer Adison Buongiorno-Smith Juliane Lovich Amanda Berkowitz Jeanne Sandoval Joel Price Madison Lawrence Stanley Mesen Wendy Romo DeAdra Jordan Rubicela Rodriguez Anna Hadlock Anna Sealander-Hulbert Marlon Carlo Estella Jeni Massi Alenika Andreev Kathleen Kim Hannah Song Kook Elisa Fry Leonard Christiana Robinson Jasmin Alfonso David Sudyka Pennie Alvarez Trenise Rahman Gayane Melikyan Adriana Estella Guarderas Anthony Carletello Elizabeth Wray Jessica Perez Amanda Romero Brianne Flexen Julie Wions Xiomara Morales Sathi Datta Previous Submit
