First Name*:

Last Name*:

Your Email*:

Phone Number*:

Street Address*:

City*:

State*:
---Outside USAAlaska Alabama Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Lousiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Zip Code*:

Best time to reach you?*
AM PM 

Gender of Topamax user:*:
Male Female 

Did the mother of the child take Topamax during the first or second trimester of pregnancy? *
Yes No 

Did your (or the mother's) child experience any of the following: *:
 Heart Ventricle Outflow Track Defects Atrial Septal Defect A Ventrical Septal Defect Persistent Pulmonary Hypertension in Newborn Other Heart Defects Other Lung Defects Other Birth Defects Pulmonary Stenosis Attempted Suicide Asthma Pre-term Labor Heart Murmur Cleft Palate/ Cleft Lip Miscarriage Fetal Death Other

Date of Birth of Child:*:

---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

---201220112010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950

Please further describe Topamax injury:

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You understand and agree to the following: your case may be evaluated by an attorney. You may be contacted by a represenative of a firm about this matter and the submission of your information in no way constitutes an attorney-client relationship.