Title Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.
* First Name
* Last Name
* Email Address
* Phone Number
Cell Phone Number
Office Phone Number
Street Address
Apartment/Suite
City
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Zip Code
Please provide the best method and times to contact you:
When was DES taken?
Date of birth of person injured (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 MicrophallusInfertilityEpididymal CystGenital DefectsBreast Cancer
Please further describe side effects:
Other Info:
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