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PERSONAL INFORMATION

First Name:

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Address:

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Date of birth of injured person:

TRASYLOL LAWSUIT INFORMATION

Date of surgery:

Have you (or injured party) experienced any of the following? (check all that apply)

Kidney failure
Stroke
Heart attack
Heart failure
Encephalopathy/brain disease
Death

Did you (or injured party) require dialysis? Yes No

Please describe the side effects you experienced:

Other information:

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