Mark & Associates, P.C. Attorneys At Law

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State ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASU.S. VIRGIN ISLANDSUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

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Date of birth of injured person (mm/dd/yyyy)

Date of your MRI or MRA (mm/dd/yyyy)

Were you injected with a gadolinium-based contrast agent? Yes
No

If so, do you know which contrast agent was administered? Magnevist MultiHance Omniscan OptiMARK ProHance

Have you been diagnosed with the skin disorder NSF/NFD? Yes
No

Please describe kidney problems / failure:

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