First Name *

Last Name *

Phone Number *

Email *

Were you prescribed any of the following? Select all that apply:

Suboxone Brand FILMS

Suboxone Brand TABLETS

Generic FILMS

Generic TABLETS

None of the above

Approximately what year did you begin taking Suboxone?200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Have you had dental damage resulting in at least 3 teeth becoming lost or extracted after starting suboxone? *

Yes

No

Approximately what year did you start noticing the dental damage? *

Is your dental damage documented by a dentist or oral surgeon? *

Yes

No

In addition to Suboxone, have you ever used any of the following? Select all that apply: *

Heroin

Methadone

Methamphetamine

Prescription Pain Medication

None of the above

In which state do you currently reside? *

Are there any additional details you would like to share about your case?

Submit