Please complete this questionnaire accurately and completely as the amount we may recover for you depends upon the information provided to us. All of your answers are completely confidential and are protected by the attorney-client privilege.

 

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Please keep everything you have that is related to your case, your injuries, and your recovery.

Please do not discuss this case or your injuries on the Internet in any capacity (i.e., Facebook, Twitter, email, etc.) or with anyone other than your attorneys and/or your spouse or partner.

Please remember to attach (if applicable):

  • Copy of death certificate
  • Copy of legal representative appointment
  • Proof of use (copies/photographs of receipts, Zantac bottles and/or packaging)
  • Copies (not originals) of your medical records for your cancer diagnosis and treatments.

THIS QUESTIONNAIRE IS STRICTLY CONFIDENTIAL AND WILL NOT BE RELEASED TO ANYONE OUTSIDE OF COFFEY TRIAL LAW