Zantac Form

General Information

Representative Information (If other then injured party)


Have You Been Diagnosed With Cancer?

Medication Usage

**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.