Zantac Intake Questionnaire - Fetterman & Associates, PA
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Zantac Intake Questionnaire

(If Injured Person Is Deceased)

Have you been diagnosed with any of the following cancers?

(1st tier)

Stomach cancer

Month/year dx :

State dx:

Small Intestine cancer

Month/year dx :

State dx:

Colorectal cancer

Month/year dx :

State dx:

Esophageal cancer

Month/year dx :

State dx:

Liver cancer

Month/year dx :

State dx:

Bladder Cancer

Month/year dx :

State dx:

(2nd tier)

Prostate cancer (decline if 65+ at time of dx)

Month/year dx :

State dx:

Pancreatic cancer

Month/year dx :

State dx:

Leukemia

Month/year dx :

State dx:

Non-Hodgins Lymphoma

Month/year dx :

State dx:

Multiple Myeloma cancer

Month/year dx :

State dx:

Other Cancer:

Month/year dx :

State dx:

Recall notification, Pill Bottles and Pills

**** Please be sure to save all evidence of Zantac, including any proof of purchase, receipts, packaging, boxes, etc. ****

Address

NORTH PALM BEACH
NORTH PALM BEACH

648 US Highway One
North Palm Beach, FL 33408
Phone: 561-983-4771

NORTH PALM BEACH
PORT ST. LUCIE
PORT ST. LUCIE

1225 SE Port Saint Lucie Boulevard,
Port St. Lucie, FL 34952
Phone: 772-344-5515

NORTH PALM BEACH

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