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* Click on the Disclaimer, below, for Terms PERSONAL INFORMATION
First Name:
Last Name:
E-mail Address:
Address:

City:
State:
Zipcode:
Phone:	-
INCIDENT INFORMATION
Which PPI (acid reflux, ulcer) drugs did you take?	Acipex Nexium Other Prilosec Prevacid Protonix
For how many years were you taking the PPI (acid reflux, ulcer) drugs?
Date you started to take PPI drugs
Date you stopped taking PPI drugs
Did you suffer a fracture during or soon after taking this medication?	Yes No
Have you developed Osteoporosis?	Yes No
Please describe your injuries and treatment:

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