PFAS Intake Form

Full Name *

Phone Number *

Email Address *

Address

Street Address *

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code

5.DOB of Injured Party *

6. Last 4 of SS of injured party *

7. Are you calling on behalf of yourself or someone else? *

Myself
Someone Else
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If on behalf of someone else, caller must have Power of Attorney or be legally authorized to file a claim on their behalf. If not, Disqualify.

What is your relationship with this person?

8. If on behalf of someone else, are they deceased? If so, did the death occur within the past year? *

YES (Continue)
NO (Disqualify)
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Is the death causally related to one of the conditions listed in #9? *

YES (Continue)
NO (Disqualify)
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9. Were you/loved one diagnosed with any of the following diseases (indicate all that apply)? *

Kidney Cancer
Testicular Cancer
Ulcerative Colitis
Hypothyroidism / Thyroid Disease
None of the above (Disqualify)
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10. Date or approximate date of diagnosis (for each diagnosed condition under #9)?

If date(s) of diagnosis are all before 2000, Disqualify.

11.Who was the diagnosing doctor (for each condition under #9)?

12. Who is the current treating doctor, if different than diagnosing doctor (for each condition under #9)?

13. What pharmacies have you used since the initial diagnosis date? (e.g., CVS, Walgreens, Walmart)

14. Have you/your loved one (1) lived on or very near to and/or (2) worked on a military base/installation and/or known PFAS contaminated facility in the United States? *

YES (continue)
NO (Disqualify)
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Which base/instillation/facility lived and/or worked?

Specify if lived near or on each base/instillation/facility.

What date range(s) did you (1) live on/very near and/or (2) worked on each base/instillation/facility?

15. 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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16. Did your/your loved ones begin consuming PFAS contaminated water at least six months prior to diagnosis? *

YES (Continue)
NO (Disqualify)
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17. Have you/loved one had a blood test for PFAS? *

YES
NO
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If tested positive, what was the result (nanograms per milliliter) and can they provide a copy of the results? *

If tested negative, Disqualify

18. 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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19. 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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20. What is the best time for the law firm to reach you?

Do you have any records or documentation of your diagnosis? Kindly ensure that your records are readily available should the law firm require them.

This is just "good to know" information and not an official qualifying question.

Do you have access to MyChart?

Yes

Mychart is a personal health record portal.

Driver's License Number

Law Firm Name

Rafferty, Domnick, Cunningham, Yaffa PLLC-PFAS
Rafferty, Domnick, Cunningham, Yaffa PLLC-Depo-Provera
Magazine Law Group - PFAS
Pulaski Kherkher Law Firm, PLLC
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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.