Did you ingest Zantac (Ranitidine)? *YesNo
Did you take the brand or generic form of Zantac (Ranitidine)?:
Were you diagnosed with cancer? *YesNo
If so, which type of cancer were you diagnosed with? (Please check all that apply.)Bladder cancerKidney cancerPancreatic cancerBreast cancerLiver cancerProstate cancerColon and Rectal cancerLung cancer (non-smokers)Stomach cancerEsophageal cancerNasal/Throat CancerTesticular cancerIntestinal cancerNon-Hodgkin lymphomaThyroid cancerKidney cancerOvarian cancerUterine cancer
Please provide details.
Name *
Email *
Primary Phone *
Secondary Phone
Street Address *
City *
State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code *
Best time to reach you *
DISCLAIMER: The contents of this contact form are being provided so that Hawkins & Walker, PC can evaluate your case. Upon evaluation, Hawkins & Walker, PC may send a new client contact, which contains a formal representation agreement and instructions for payment. This form does not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. An attorney-client relationship will only be created upon your acknowledgment of the terms contained in the Municipal Citation Retainer Agreement and payment of applicable attorneys’ fees.
I confirm that I have read and foregoing disclaimer
Submit
