* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

When was DES taken? 

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:

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