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NBIA Disorders Association B5 Experiences Form
The information you submit with this form will be reviewed and edited if necessary by Patricia V. Wood, President of NBIA before it is entered into the B5 Experiences web page. Of the information submitted only your first name, relationship to NBIA individual, and e-mail address, will be listed along with your comments. By submitting your comments you are agreeing to have others contact you about your experiences with B5.

 

Your Name:       E-Mail:

Street Address:

City:      State:      Zip Code:

Country:

Your relationship to NBIA individual:

Comments:
Please be sure to include this general information. B5 dosage (Please be specific: i.e., starting dosage, time intervals before increasing dosage, and current dosage. If listing side effects state at what dosage they occurred.)