(7 Digit number)

(7 Digit number)

(7 Digit number)

(7 Digit number)

**Attach copy of Appointment & Death Certificate** **ANSWER ALL QUESTIONS BELOW ON BEHALF OF INJURED PARTY**

(hold Ctrl and click to select multiple)

(month/year)

(month/year)

(hold Ctrl and click to select multiple)

(month/year)

(month/year)

(month/year)

(month/year)

(Street, City, State, and Zip)

*Please store aIl pills, bottles, and packaging in a safe place until further notice and send us a photograph of the bottle{s)/label(s).*

(Street, City, State, and Zip)

(Street, City, State, and Zip)

(Street, City, State, and Zip)

(hold Ctrl and click to select multiple)

(Street, City, State, and Zip)

(Street, City, State, and Zip)

(Street, City, State, and Zip)

(Street, City, State, and Zip)

(Street, City, State, and Zip)

***If you have any medical records, please send in a copy to our ofTice.*** Please do not send originals.

Medical History: Please indicate if you were diagnosed with any of the following conditions before you started taking Zantac/Ranitidine:

If yes, please fill in Name, Relationship, and Type below

(Street, City, State, and Zip)

(Street, City, State, and Zip)

(hold Ctrl and click to select multiple)