Zolfran Intake Form

* First Name

* First Name

* Email Address

* Phone Number (your best contact number please)

*Street address

* City

* State
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* Zip Code

*While taking Zolfan during pregnancy has your child suffered any of these injuries:
 Cleft Lip Cleft Palate Heart Defects Wrongful Death Any Other Birth Defects

* Were you (or a loved one) hospitalized as a result of the injury specified? Yes No Yes No
* Please provide a brief description of your injuries or diagnosis:

Agreement*

I Understand and agree that submitting this form does not create an attorney-client relationship and that the information I submit is not confidential and may be shared with our co-counsel and associates for review. I further understand and agree to the Terms of Use and Privacy Policy.