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Hilliard Martinez Gonzales, LLP
Gilead Medical Provider Survey
Medical Provider Survey
Hidden
Case ID
First Name
Last Name
Address
Phone
Email
Is the above contact information correct?
Select
Yes
No
Who is your current primary care provider?
Primary Care Name/Facility
Primary Care Address
When did you start seeing your primary care provider?
MM slash DD slash YYYY
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?
MM slash DD slash YYYY
For any injuries related to your kidneys, please list your treating kidney physician (including nephrologist).
I do not have a treating kidney physician.
I do not have a treating kidney physician.
Kidney Physician name/facility
Kidney physician Address
When did you start seeing your treating kidney physician?
MM slash DD slash YYYY
For any injuries related to your bones, please list your treating bone physician.
I do not have a 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?
MM slash DD slash YYYY
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?
MM slash DD slash YYYY
Pharmacy 2 Name/Facility
Pharmacy 2 Address
When did you start filling your prescription at pharmacy 2?
MM slash DD slash YYYY
Do you have any new or worsening injuries to your kidneys?
Yes
No
What is your new or worsening kidney injury diagnosis?
What date were you diagnosed with your new or worsening kidney injuries?
MM slash DD slash YYYY
Who is your treating doctor for you new or worsening kidney injuries?
Do you have any new or worsening injuries to your bones?
Yes
No
What is your new or worsening bone injuries diagnosis?
What date were you diagnosed with your new or worsening bone injuries?
MM slash DD slash YYYY
Who is your treating doctor for your new or worsening bone injuries?
