Zantac Form Home / Zantac Form General Information State 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 Representative Information (If other then injured party) Diagnosis: Have You Been Diagnosed With Cancer? Please select the disease you have been diagnosed with: Bladder Cancer Brain Cancer Breast Cancer Colorectal Cancer Colon Cancer Esophageal Cancer Intestinal Cancer Kidney (Renal) Cancer Liver Cancer Lung Cancer Non-Hodgkin Lyphoma Ovarian Cancer Pancreatic Cancer Prostate Cancer Stomach Cancer Testicular Cancer Throat/Nasel Cancer Thyroid Cancer Uterine Cancer Have you smoked in the past 25 years? Yes No Please Specify Medication Usage Please select the brand used*: Zantac Prescription Zantac OTC Generic Prescription (Ranitidine) Generic OTC (Ranitidine) **Based on the information you have submitted, it is our opinion that you may not qualify for the lawsuit. To be clear, we are not rendering any legal advice and we are not representing you as attorneys in any capacity. You have the right to consult an attorney directly if you wish to proceed with your potential claim. If that is the case, please do so immediately. Thank you. Submit Form Your Message Has Not been sent. Try again later.