Zantac Pre-Qualification Form

1. Select one of the following:*

I am an adult who took Zantac and was diagnosed with cancer.
I am an adult who took Zantac while pregnant, and my child was diagnosed with cancer.
I am an adult who took Zantac while pregnant, and my child was diagnosed with birth defects.
I am an adult who took Zantac while pregnant, and I suffered a miscarriage or stillbirth.
My child took Zantac and was diagnosed with cancer.

Were you diagnosed with cancer within 10 years of the last Zantac use?*

Yes
No

Did the adult have at least 1 year of use prior to the cancer diagnosis?*

Yes
No

Was the child diagnosed with cancer within 1 year of their own last Zantac use?*

Yes
No

Did the child have at least 1 year of use prior to the cancer diagnosis?*

Yes
No

Did the mother use Zantac for at least 6 months while pregnant?*

Yes
No

Was the child diagnosed with cancer within 5 years after birth?*

Yes
No

You do not currently qualify.

Name*

First Last

Email*

Phone*

ID Number for Purchase Tracking

If you purchased a brand of OTC Zantac, your Walgreens Prescription Savings Club, CVS ExtraCare, Hyvee Prescription Discount, Costco, Sams Club, or any other card ID number will help us track your purchase history of this drug. Please provide that number here if available.

By submitting this form you are agreeing to be contacted by an attorney or other law firm staff.

Zantac Pre-Qualification Form

Please answer the following questions to see if you qualify.

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