Gender of Wellbutrin (bupropion HCI) user*:
 Female Male

Did the mother of the child take Wellbutrin (bupropion HCI) during the first or second trimester of pregnancy?*:
 Yes No

Which drug was prescribed?*:
---WellbutrinWellbutrin XLWellbutrin SRBupropionGeneric FormOther

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 Pulmoonary Hypertension in Newborn Attempted Suicide Asthma Miscarriage Fatal Death Other Heart Defects Other Lung Defects Other Birth Defects Pulmonary Stenosis Other

Date of Diagnosis*:

---MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

---Year2022202120202019201820172016201520142013201220112010 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

Date Birth of Child*:

---MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

---Year2022202120202019201820172016201520142013201220112010 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 injury/illness*:

Contact Information

First Name*:

Last Name*:

Your Email*:

Phone Number*:

Street Address*:

City*:

State*:
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Zip Code*:

Best time to reach you?*
 AM PM

Enter the captch code*:

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.