Serzone (inducing violence and suicide)

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Defendant:
(who caused the harm?)

Serzone (violence and suicide)

*Describe your complaint:
(briefly describe the damages you have suffered)

Date Serzone was started (and/or stopped):

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

Name of Dr. who prescribed Serzone:

How many incidents of violent behavior have occurred?

How many police reports are available about these incidents?

How many suicide attempts have occurred?

Are hospital records available about these suicide attempts?

*What is the age of the person taking Serzone?

Do you have a copy of your medical records?

Yes No

Can you get a copy of your medical records?

Yes No

*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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Serzone (inducing violence and suicide)