Identify the total period of time you were treated with TRT: Were there times when your TRT treatment was discontinued during that period? Yes _____ No _____ Don’t Recall _____ Complete the following chart with respect to each TRT medication to identify each product with which you were treated: How Often Prescribing Pharmacy Approx Dates Drug Name Administered Physician That Dispensed of Use or Applied If you were treated with TRT, but do not presently recall the name of the drug, provide the information requested below: Type: (Patch, Prescribing or Pharmacy or Gel, Injection, Dispensing Date(s) of Dates of Use store where Tablets, Pellets Health Care purchase purchased or Capsules) Provider Identify any other relevant information to support and/or identify how you obtained your TRT: __________________________________________________________________ If any gaps of time in your usage of any TRT product, please identify: _______________ Produce all records or other information that documents that you or someone on your behalf was dispensed prescriptions and/or samples of the TRT products used by you prior to the date of your alleged TRT-related injuries (this information may include, but is not limited to, pharmacy records, prescription records, personal notes, medical records and/or sworn statements from prescribing healthcare provider or any other healthcare providers). Did you ever receive any samples of TRT? Yes _____ No _____ Don’t recall _____ If yes, identify who gave you the sample, when you received it, the specific products included in the samples, and how many samples you received: whether you requested TRT from any Health Care Provider. Yes _____ No _____
Identify the total period of time you were treated with TRT: Were there times when your TRT treatment was discontinued during that period? Yes _____ No _____ Don’t Recall _____ Complete the following chart with respect to each TRT medication to identify each product with which you were treated: Drug Name Prescribing Physician Pharmacy That Dispensed Approx Dates of Use How Often Administered or Applied If you were treated with TRT, but do not presently recall the name of the drug, provide the information requested below: Type: (Patch, Gel, Injection, Tablets, Pellets or Capsules) Dates of Use Prescribing or Dispensing Health Care Provider Pharmacy or store where purchased Date(s) of purchase Identify any other relevant information to support and/or identify how you obtained your TRT: __________________________________________________________________ If any gaps of time in your usage of any TRT product, please identify: _______________ Produce all records or other information that documents that you or someone on your behalf was dispensed prescriptions and/or samples of the TRT products used by you prior to the date of your alleged TRT-related injuries (this information may include, but is not limited to, pharmacy records, prescription records, personal notes, medical records and/or sworn statements from prescribing healthcare provider or any other healthcare providers). Did you ever receive any samples of TRT? Yes _____ No _____ Don’t recall _____ If yes, identify who gave you the sample, when you received it, the specific products included in the samples, and how many samples you received: whether you requested TRT from any Health Care Provider. Yes _____ No _____
Amended%20PFS.DOCX