Your Name:

E-mail address to send information to:

Telephone Number (optional):

What diet drugs did you use:

Did you file the Orange Form to opt out by March 30, 2000?
Yes No

If yes, do you have a copy of the Orange Form you submitted?
Yes No

Do you have proof of your use of the Diet Drug?
Yes No

If yes, what type of proof of use do you have?
To select more than one, press the Control key while you make your selections.

Have you been diagnosed with any heart valve damage?
Yes No

If yes, what was your diagnosis?

What was the date of your echocardiogram?

Any other information you would like to let us know:

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