PFAS Intake Form
Last Name
First Name
Phone Number
*
Email Address
*
City
State
Postal code
Were you/loved one diagnosed with any of the following diseases (indicate all that apply)?
*
Kidney Cancer
Testicular Cancer
None of the above (Disqualify)
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Date or approximate date of diagnosis (for each diagnosed condition under #9)?
If date(s) of diagnosis are all before 2000, Disqualify.
Have you/your loved one drink from contaminated water supply from 1990 to present for at least six cumulative months?
*
YES (Continue)
NO (Disqualify)
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Are you/your loved one willing to undergo blood testing, if needed, to establish your exposure to PFAS? The law firm will cover the expenses.
*
YES (Continue)
NO/Unsure, Disqualify
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Are you willing to communicate by phone with an attorney or case manager about your potential claim and confidentially share medical records and personal health information related to your PFAS injuries.
*
YES (Continue)
NO (Disqualify)
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Are you currently being represented by an attorney?
If yes, are interested in seeking new representation?
No
Yes
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What is the best time for the law firm to reach you?
Fraud Statement
I certify that to move forward with this claim, the information I provided is truthful to the best of my knowledge and I have not committed perjury, which is the act of falsifying an affirmation on this call or any call related to this matter.
SUBMIT