ONLINE CASE EVALUATION FORM
If
you have been diagnosed with Mesothelioma and would like an attorney with
experience handling mesothelioma cases to review your situation, please complete
the following. * required fields
Full Name:
*
Phone:
*
Additional Phone:
Email Address:
Street:
City:
*
State:
*
Zip:
Name of the Injured
Person:
Your Relationship to the Injured:
Are you seeking
legal assistance because you have lost a loved one to Mesothelioma?
Yes
No
Has
a medical diagnosis of Mesothelioma been made?
Yes
No
Did asbestos exposure occur in the workplace?
Yes
No
What was
the occupation when the asbestos exposure occurred (roofer, miner, insulation
installer, construction worker, factory worker)?
When do you think asbestos exposure occurred?
How long have/did you worked in an environment where
there is a possibility for asbestos exposure?
Do you smoke?
Yes
No
If
you have been diagnosed with Mesothelioma, what medical treatment options have
been identified? Tell us more about your medical situation and current
treatment:
If you were exposed to asbestos in the work
environment, were there safety procedures in place? Did the company provide you
with warning or advise you about the risks?
Do you know if any co-workers have suffered
medical injuries due to asbestos or the work environment?
Yes
No
Please provide us with
any additional information and submit any questions you may have at this time:
Yes - I agree that I am not forming an attorney
client relationship by submitting this question. I understand that I may only
retain an attorney by entering into a fee agreement, and that I am not
entering into a fee agreement by submitting this question. I agree that the
information that I will receive in response to the above question is general
information and I will not be charged for the response to this e-mail
question. I further understand that the law for each state may vary. Since
this matter may require advice regarding states other than New York, I agree
that local counsel may be contacted for referral of this matter.
By Clicking the appropriate box below, I agree to submit my case for
evaluation:
DISCLAIMER:
The content of
this mesothelioma web site has not been prepared or endorsed by licensed medical
professionals. This site should be taken as medical advice. The purpose of this
site is to provide mesothelioma victims with useful information and access to
other mesothelioma resources, which may be helpful. Those injured by asbestos
and suffering with mesothelioma are encouraged to consult with their physician
for medical advice and with an mesothelioma lawyer for legal advice.
