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First Name

Last Name

Email Address

Phone Number

Cell Phone Number

Street Address

City

State
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Date of birth of Chantix patient (mm/dd/yyyy):

Age of patient when Chantix was prescribed (mm/dd/yyyy):

Was suicide attempted after taking Chantix?
Yes
No

Did attempted suicide result in death?
Yes
No

Was hospitalization or institutionalization required after taking Chantix?
Yes
No

If yes, please describe hospitalization or institutionalization:

Please further describe your side effects / experience while taking Chantix:

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