Name

Phone Number

E-mail Address

Were you a patient at one of the clinics in question?

Yes No

Did you receive anesthesia or sedation injections?

Yes No

Have you been tested recently for hepatitis or HIV?

Yes, Tested Positive
Yes, Tested Negative
Yes, Results Pending
No, Not Tested

What side effects did you suffer?

Were you married or engaged while being treated at one of the clinics in question?
Yes No

Do you have any children?
Yes No

Were you or your significant other pregnant during the time you were treated by the clinic in question?
Yes No

Additional Details