Are you calling on behalf of yourself or a loved one?

    Have you or the injured party signed an agreement with another attorney to represent you regarding your Zantac related cancer? 

    Caller First Name:

    Caller Last Name:

    Caller Phone:

    Injured Party First Name:

    Injured Party Middle Name:

    Injured Party Last Name:

    Relationship of Personal Representative to Injured Party:

    Cell Phone:

    Street Address:

    Street Address 2:

    City:

    State:

    ZIP Code:

    Email Address:

    Best Time To Reach:

    Date of Birth:

    Social Security Number:

    Did you take the brand name medication Zantac?

    Did you obtain the medication by prescription?

    What is the name of the pharmacy you obtained your Zantac prescritption? Do you have the street name or address?

    Were you diagnosed with cancer after taking this medication?

    Approximately when did you start taking the medication?

    How often did you use Zantac?

    Prior to your cancer diagnosis, did you take Zantac for at least 1 year?

    Did you take a minimum of 4 pills a week during the 1 year period of using Zantac?

    Approximately how long did you take the medication in total prior to your cancer diagnosis? (In years and months)

    Who was your diagnosing doctor?

    What type of cancer did they diagnose you with?

    Date of Diagnosis:

    What treatments were required for your cancer?

    Did you stop taking Zantac?

    Approximately when did you stop taking the medication?

    Were you ever notified of any Zantac recalls?

    Did you receive any free samples of Zantac?

    Do you still have the Zantac packaging?

    Would you be willing to provide pictures of the old packaging to our law firm?

    When did you first come to believe that your cancer diagnosis could be related to the use of Zantac?

    Have you ever smoked tobacco-based cigarettes or products?

    Do you know if there is a family history of cancer? If so, which ones?

    Are there any other details that the attorney should know?

    Do you want to receive the contract via mail or electronically?

    IF ELECTRONICALLY: Who is legally authorized to sign?

    IF VIA MAIL: Which party is legally authorized to sign?