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Salutation: Please select Mrs. Ms. Mr.   *First name: *Last name: *Address: *City: *State: Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip code: *Gender: Please select Female Male

*Birthdate: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901

*E-mail: *Re-enter  e-mail:

*I have had a full-body DXA/bone density test (one where I had to lie down) within the last 2 years. Yes No *My doctor told me I have osteoporosis/osteopenia (low bone mass). Yes No *I am taking a prescription medication for osteoporosis. Yes No

If yes, which one? Please select ACTONEL® (risedronate sodium) tablets Fosamax® (alendronate sodium) tablets and oral solution Boniva® (ibandronate sodium) tablets Evista® (raloxifene hydrochloride) tablets Premarin® (conjugated estrogens, USP) tablets Miacalcin® (calcitonin-salmon) Nasal Spray Reclast® (zoledronic acid) infusion Other

When did you start taking ACTONEL? Month January February March April May June July August September October November December Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ACTONEL is for the treatment of postmenopausal osteoporosis.
Your doctor may also prescribe ACTONEL to help prevent postmenopausal osteoporosis.

Important Safety Information for
ACTONEL^® (risedronate sodium) tablets

You should not take Actonel if you are allergic to any of the ingredients, if you have low blood calcium (hypocalcemia), have kidneys that work poorly, or cannot stand or sit upright for 30 minutes.

Stop taking Actonel and tell your doctor right away if you experience difficult or painful swallowing, chest pain, or severe or continuing heartburn, as these may be signs of serious upper digestive problems. Follow dosing instructions carefully to lower the chance of these events occurring.

Side effects may include stomach pain, upset stomach, or back, muscle, bone or joint pain, sometimes severe. Contact your doctor for medical advice about side effects, or if you have questions about Actonel. Promptly tell your doctor if you develop dental problems, as serious jawbone problems have been reported rarely.

Please see ACTONEL Patient Information.