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Hilliard Martinez Gonzales, LLP
Zantac Additional Questions
Hidden
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.)
I am bringing claims on behalf of a loved one who has died
The person who was hurt is under 18 and I am that persons parent
I was appointed legal guardian of the person who was hurt by Zantac
None of these
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
MM slash DD slash 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
MM slash DD slash 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)
California
Vermont
Massachusetts
Illinois
I don’t know
None of these
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)
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
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)
Walgreens
CVS
Rite-Aid
Safeway
Walmart
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)
Comments
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