Zantac Additional Questions – Hilliard Martinez Gonzales, LLP

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Case Number

First Name*

Last Name*

Last 4 of SSN*

Are you the person who was physically hurt by taking Zantac (either by developing cancer or being afraid that you will develop cancer)?

Yes
No
Unknown
N/A

Are you bringing claims on behalf of yourself or someone else?

myself
someone else

If you are bringing claims on behalf of someone else, please select all that apply: (click the box below to see options) (If you are bringing claims on behalf of yourself, please go to question 7 and answer question 7 and those questions after 7 with regard to YOUR Zantac use.)

7. What is the injured person’s name?

If you are bringing this case on behalf of a loved one who has died, what is the date of death? mm/dd/yyyy

If you are bringing the case on behalf of someone who died, has an estate been opened through the probate court?

Yes
No
Unknown

Has the injured person been diagnosed with cancer?

Yes
No
Unknown

If yes, please provide date of diagnosis mm/dd/yyyy

Please confirm that the injured person has taken brand name Zantac (either over-the-counter or prescription) at least once.

Yes
No
I don't know

Did the injured person use Zantac in any of the following states? (click the box below to see options, select all that apply)

Did the injured party develop any of the following after starting to take Zantac: (click the box below to see options, select all that apply)

Please list the doctor(s) who diagnosed any of the conditions listed above. Please list Doctors' Name, City, State, Phone and separate different doctors by semi colon (Ex: Dr. Doe, CC, TX, 361-882-1612; Dr. Smith, Houston, TX, 713-555-5555)

I dont know who diagnosed, but I can find out.

Yes
No

Please list any doctor(s) who prescribed Zantac to the injured party. Please list Doctors' Name, City, State, Phone and separate different doctors by semi colon (Ex: Dr. Doe, CC, TX, 361-882-1612; Dr. Smith, Houston, TX, 713-555-5555)

Im not sure who prescribed Zantac, but I can find out.

Yes
No

Please list every doctor who recommended Zantac to the injured party. Please list Doctors' Name, City, State, Phone and separate different doctors by semi colon (Ex: Dr. Doe, CC, TX, 361-882-1612; Dr. Smith, Houston, TX, 713-555-5555)

I dont know who recommended Zantac, but I can find out.

Yes
No

Please list every other doctor(s) the injured person saw in the last 10 years. Please list Doctors' Name, City, State, Phone and separate different doctors by semi colon (Ex: Dr. Doe, CC, TX, 361-882-1612; Dr. Smith, Houston, TX, 713-555-5555)

I dont know the doctors seen, but I can find out.

Yes
No

Please identify all the pharmacies where the injured person filled the prescription for Zantac or bought over-the-counter Zantac (click the box below to see options, select all that apply)

Please list any other pharmacies where the injured person filled the prescription for Zantac. Please list pharmacy's Name, City, State, Phone and separate different pharmacies by semi colon (Ex: Dr. Doe, CC, TX, 361-882-1612; Dr. Smith, Houston, TX, 713-555-5555)

Name

This field is for validation purposes and should be left unchanged.

High blood pressure
Bladder and kidney infections
Blood in urine not caused by an infection
Unexplained appetite loss or weight loss of more than 10 pounds
Gallstones
Uncontrollable bladder
Inguinal Hernia
Nodules in lungs
Erectile dysfunction
Chronic Kidney disease
Fibromyalgia
Adenomas or adenomatous polyps
Diverticulitis
Guillain Barre Syndrome
Low kidney function
Kidney failure
Pancreatitis
High blood pressure
Dysphagia or difficulty swallowing
Gastric ulcers
Peptic ulcer
Chronic Pancreatitis not caused by smoking or heavy alcohol use
Hepatitis
Jaundice
Decreased kidney function/kidney failure
Lump anywhere on body
Diagnosed precancerous condition
Persistent bowl changes
Consistent difficulty swallowing
None of these
I don’t know