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Title Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.
* First Name
* Last Name
* Email Address
* Phone Number
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Street Address
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* Date Of Birth Of The Person Taking Paxil (mm-dd-yyyy)
* Date Of Birth Of Child With Birth Defect (mm-dd-yyyy)
Date you started taking the drug (mm-yyyy):
Date you stopped taking the drug (mm-yyyy):
Were You Taking Paxil During The First 3 Months of PregnancyYesNo
What Type Of Birth Defect Did The Child Sustain
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