Inflammatory Bowel Disease
Premature Closure of Growth Plates
Birth Defects
Ulcerative Colitis
Crohn's Disease
Inflammatory Bowel Syndrome
Rectal Bleeding
Abdominal Pain
Central Nervous System Injuries
Bone and Muscle Loss
Cardiovascular Injuries
Liver and Kidney Damage
Pancreatitis
Immune System Disorder
Lupus
Hearing and Vision Damage
Thyroid Disorders
Suicidal Thoughts & Behavior

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First Name Last Name Email Address Phone Number Cell Phone Number Street Address City State Zip Code Date of birth of injured person (mm-dd-yyyy): Date you started taking Accutane (mm-yyyy): Date you stopped taking Accutane (mm-yyyy): Did you experience any of the following side effects?
(check all that apply)
Ulcerative Colitis
Crohn's Disease
Inflammatory Bowel Disease
Rectal Bleeding
Irritable Bowel Syndrome (IBS)

Please further describe side effects:
Other Comments:

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