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Paxil Suicide (violence and suicide)

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Defendant:

Paxil Suicide(violence and suicide in children)

*Describe Damages you Suffered:

Date Paxil was started (and/or stopped):

Name of Dr. who prescribed Paxil:

Other prescription drugs you are taking, date started and date finished:

How many incidents of violent behavior have occurred?

How many police reports are available about these incidents?

How many suicide attempts have occurred?

*What is the age of the person taking Paxil?

Are hospital records available about these suicide attempts?

Yes No

Do you have a copy of your medical records?

Yes No

Can you get a copy of your medical records?

Yes No

Comments:

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

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