Xarelto: Client Criteria Questionnaire

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Did you take Xarelto or a generic version? Please take a picture of your prescription or pill bottle and upload it here:

Did you have a bleeding event resulting in hospitalization (or did the patient die)? *

If so, how long were you kept in the hospital? *

Did you receive a transfusion while in the hospital? *

How long after taking Xarelto did the bleeding event occur? *

What was the date of the bleeding event? *

Are you still taking Xarelto? If not, what drug are you taking now? *

Checkboxes *

Phone

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