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Fill out this brief form to find out if you have a Raptiva Lawsuit:

First Name:
Last Name:
E-mail:
Address:
City:
State:
Zipcode:
Phone:
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Have any of the following symptoms or injuries occured:
Brain Infection
Loss of Vision
PML
Death
Problems Walking
Speech Problems
Other Serious Infections
Dates Raptiva injections were received:
Start Date:
End Date:
Are you still receiving injections?
Yes No
Please describe any side effects:
Other comments / questions: