Abelson - LFSB Digitek Client Intake - Free Claim Review

General Info

Name:

Address:

State:

Phone:

DOB of patient taking Digitek:

City:

Zip Code:

Email:

Drug Information

Dose:

125mg:

250mg:

Frequency taken per day?

How long have you taken?

Why taking Digitek?

Heart Failure (Congestive Heart Failure / CHF)

Atrial Fibrillation (heart rthym problem)

Other (please specify)

Did you return Digitek to any Pharmacy?
 Yes
No

If yes, name / address/phone of pharmacy?

Injury Alleged

How do you believe that Digitek has injured you?

How have you been affected by Digitek?

Heart attack

Stroke

Kidney Failure

Other (please specify)

Have you sought medical care for this injury?
 Yes
No

If yes, with whom?