Lung Transplant Free Case Review


Contact Information
* denotes a required field
First Name*
Last Name
  only one number is required
Home Phone* - -
Work Phone* - -
Cell Phone* - -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip  
 
Injured Person Contact Information
The injured person is
First Name:
Last Name:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
Email Address:
Street Address:
City:
State/Zip  
Date of Birth
Sex Male  Female
 
Medical Information
Have you or a loved one had a lung transplant?
Yes
No
Are you or a loved one on a lung transplant waiting list?
Yes
No
Are you or a loved one on oxygen at this time?
Yes
No
What is/was the reason for a lung transplant or oxygen?
What were you told about your lung disease?
Have you been diagnosed with mesothelioma?
Yes
No
 
Employment History
Have you ever worn a dust mask or respirator at work?
Yes
No
What kind of mask or respirator did you wear?
Have you ever worn a disposable or throw-away type mask?
Yes
No
Have you ever worn a rubber type of mask with filters that you replaced?
Yes
No
If you have worn a dust mask or respirator at work, do you have a respirator at home or do you have the package or box it came in?
Yes*
No
*Note: If so, please save it as we may need it for your case. It is very important that you do so.
Is the injured person deceased?
Yes
No
If deceased please list the names and phone numbers of co-workers who can tell us about respirator/dust mask use.
Co-worker #1:
Name:
Phone: - -
 
Co-worker #2:
Name:
Phone: - -
 
Co-worker #3:
Name:
Phone: - -
 
Prior Lawsuits
Have you ever filed a lawsuit for lung disease?
Yes
No
Have you ever filed a workers compensation claim for lung disease?
Yes
No
Who was your attorney?
Is this case still ongoing?
Yes
No
If resolved, what was the result?
 
a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. 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, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.
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