McGlynn Glisson & Koch - A Professional Law Corporation

McGlynn, Glisson & Koch is committed to protecting the rights and welfare of the individual.


340 Florida Street
Baton Rouge, LA
70801-1304

Phone: (225) 344-3555
Fax: (225) 344-3666
Email the Firm

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© 2003 McGlynn Glisson & Koch

 

 

Tardive Dyskinesia Form

NOTE:  An Asterisk (*) Indicates REQUIRED Information.

Date of Contact:
*Client Name:  

Address: Work Phone:
City: Home Phone:
State: Cell Phone:
Zip: *E-mail Address:
DRUG (S):
Duration of Exposure:
Date of 1st exposure
Date of Last Exposure
Date of Discovery of TD:
Defendant Doctors:
Psychiatric Diagnosis:
Hospitalizations
(how many/how long):
Alleged Indication for Neuro:
Type of Movement/Severity:
TD Verified by Diagnosis: Yes No By Whom:
Description of TD Treatment:

Note:

   



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