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 Provider 1 Provider 2 Provider 3 Previous Submit
