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Hilliard Martinez Gonzales, LLP

Hilliard Martinez Gonzales, LLP

Zantac Critical Information Questionnaire

  • Hidden
  • Zantac User Personal Information

  • MM slash DD slash YYYY
  • Hidden
  • Occupation Information

  • Please enter a number from 1950 to 2020.
  • Please enter a number from 1950 to 2020.
  • Bankruptcy Info

  • Please enter a number from 1950 to 2020.
  • Deceased

  • Representative

  • MM slash DD slash YYYY
  • Zantac Usage Information

  • Please enter a number from 1950 to 2020.
  • Please enter a number from 1950 to 2020.
  • Residences when Zantac was used

  • 1st residence

  • Please enter a number from 1950 to 2020.
  • Please enter a number from 1950 to 2020.
  • 2nd residence

  • Please enter a number from 1950 to 2020.
  • Please enter a number from 1950 to 2020.
  • 3rd residence

  • Please enter a number from 1950 to 2020.
  • Please enter a number from 1950 to 2020.
  • Zantac Usage - Please provide the following information for each kind of Zantac used. You will have a chance to provide this information for more than one kind of Zantac.

  • 1st Zantac use

  • Questions about prescription

  • Prescribing doctor #1

  • Prescribing doctor #2

  • Prescribing doctor #3

  • OTC recommending doctors

  • Recommending doctor #1

  • Recommending doctor #2

  • OTC – place of purchase

  • 1st place of purchase

  • 2nd place of purchase

  • Questions for both Prescription and OTC

  • 2nd Zantac use info

  • Questions about prescription

  • Prescribing doctor #1

  • Prescribing doctor #2

  • Prescribing doctor #3

  • OTC recommending doctors

  • Recommending doctor #1

  • Recommending doctor #2

  • 176. OTC – place of purchase

  • 1st place of purchase

  • 2nd place of purchase

  • Questions for both Prescription and OTC

  • 3rd Zantac use info

  • Questions about prescription

  • Prescribing doctor #1

  • Prescribing doctor #2

  • Prescribing doctor #3

  • OTC recommending doctors

  • Recommending doctor #1

  • OTC - Place of purchase

  • 1st place of purchase

  • 2nd place of purchase

  • Questions for both Prescription and OTC

  • STOP! IF THE PERSON WHO USED ZANTAC DID NOT SUFFER CANCER, YOU DO NOT NEED TO ANSWER ANY MORE QUESTIONS. JUST GO TO THE BOTTOM AND PRESS SUBMIT.

  • IF THE PERSON WHO USED ZANTAC DID SUFFER CANCER, PLEASE ANSWER THE REST OF THE QUESTIONS AND THEN PRESS SUBMIT.

  • Injury Questions

  • Please answer the questions below for every type of cancer

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.
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