Gilead Medical Provider Survey - Hilliard Martinez Gonzales LLP

Medical Provider Survey

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Case ID

First Name

Last Name

Address

Phone

Is the above contact information correct?

Who is your current primary care provider?

Primary Care Name/Facility

Primary Care Address

When did you start seeing your primary care provider?

Who is your current Infectious Disease physician?

Infectious Disease physician Name/Facility

Infectious Disease physician Address

When did you start seeing your infectious disease physician?

For any injuries related to your kidneys, please list your treating kidney physician (including nephrologist).

I do not have a treating kidney physician.

Kidney Physician name/facility

Kidney physician Address

When did you start seeing your treating kidney physician?

For any injuries related to your bones, please list your treating bone physician.

I do not have a treating bone physician.

Bone Physician Name/Facility

Bone Physician Address

When did you start seeing your treating bone physician?

Please list which pharmacy you have received TDF drugs (Truvada, Atripla, Complera, Stribild, Viread) from.

Pharmacy 1 Name/Facility

Pharmacy 1 Address

When did you start filling your prescription at pharmacy 1?

Pharmacy 2 Name/Facility

Pharmacy 2 Address

When did you start filling your prescription at pharmacy 2?

Do you have any new or worsening injuries to your kidneys?

Yes

What is your new or worsening kidney injury diagnosis?

What date were you diagnosed with your new or worsening kidney injuries?

Who is your treating doctor for you new or worsening kidney injuries?

Do you have any new or worsening injuries to your bones?

Yes

What is your new or worsening bone injuries diagnosis?

What date were you diagnosed with your new or worsening bone injuries?

Who is your treating doctor for your new or worsening bone injuries?

Please tell us who you are and how we can contact you. This information is strictly confidential and will not be shared with anyone. The information is necessary for a conflict-of-interest check that we must perform prior to responding to you. We cannot respond without performing the check. Fields marked with * are for required information.

If you are a member of the media and have a question about a case, please send us an email at
media@hmglawfirm.com and we will respond in a timely manner.

Medical Provider Survey

Who is your current primary care provider?

Who is your current Infectious Disease physician?

For any injuries related to your kidneys, please list your treating kidney physician (including nephrologist).

For any injuries related to your bones, please list your treating bone physician.

Please list which pharmacy you have received TDF drugs (Truvada, Atripla, Complera, Stribild, Viread) from.

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