Complete the form below and we will contact you immediately to help get answers!
Is another attorney representing you in regards to this matter? YESNO
Did you or a loved one use e-cigarettes? YESNO
Were you a regular smoker prior to using e-cigarettes? YESNO
Which e-cigarette brand do/did you use? JUULOTHER
Did you begin using e-cigarettes as a minor? YESNO
Do you have a documented nicotine addiction? YESNO
Did you suffer from any of the following injuries due to the use of E-Cigarette?
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
OTHER LUNG OR RESPIRATORY PROBLEM
HEART ATTACK (MYOCARDIAL INFARCTION)
MENTAL HEALTH OR BEHAVIORAL PROBLEM
NONE OF THESE
DATE OF DIAGNOSIS
Did you undergo any of the above medical treatments due to Nicotine Addiction or above mentioned injuries? YESNO
Were you hospitalized due to the injuries suffered? YESNO
STATE OF RESIDENCE?
STATE OF PURCHASE?
STATE OF USE?
Is the client deceased? YESNO
1 + 5 = ? Please prove that you are human by solving the equation *