Free Consultation

Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email

* Phone

Cell Phone

Office Phone

Street Address

Apartment/Suite

Zip Code

City

State
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Please provide the best method and time to contact you:

When was DES taken?

Date of birth (mm-dd-yyyy):

What condition was this medication prescribed to treat?

What was the name of the medication taken that contained DES?

Who has been affected by DES use (i.e. son/daughter/grandchildren)?

Have any of the following been diagnosed? (Please check all that apply.)
Clear Cell Adenocarcinoma
Microphallus
Infertility
Epididymal Cyst
Genital Defects
Breast Cancer

Please further describe side effects:

Other Info:

No Yes, I agree to the Parker Waichman LLP disclaimers.Click here to review all.

Yes, I would like to receive the Parker Waichman LLP monthly newsletter, InjuryAlert.