Last Step!

Full Name(required)

Phone Number(required)

Email Address(required)

What years did you take Xarelto or Pradaxa?(required)

What Pharmacy did you use?(required)

What type of injury/symptoms occurred? Internal Bleed

Uncontrollable Bleeding

Excessive nose bleeds

Excessive menstrual bleeding

Gastrointestinal Bleed

Cerebral hemorrhage

Other Bleed Event

What Hospital treated you for your injury?

What year did you suffer your injury?

Additional Information