Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Did you take Tylenol and/or generic brand Acetaminophen during your pregnancy? *

Yes

How many total days did you take Tylenol/Acetaminophen during your pregnancy?*

Has your child been diagnosed with Autism?*

Yes

In what year was your child diagnosed with Autism?

When would be a good time to call you?

Central Time