Mesothelioma Information Center

Asbestos and Mesothelioma Contact Form

Name

E-mail Address

Phone Number

When did you first have contact with asbestos?

Where were you when the contact occurred?

What were you doing when the contact occurred?

Who owns the property where the contact occurred?

How many times have you been exposed to asbestos?

Did you or your employer purchase the product that contained the asbestos?

Were you working at the time of the exposure? For whom?

If you encountered the asbestos at work, do you recall any training, warnings or provision of protective gear by your employer to protect you from or educate you about asbestos?

What disease or injury (mesothelioma, asbestosis, lung or other cancer) has occurred as result of the asbestos exposure?

Please list your treating physicians and other medical providers

Do you or have you smoked? How much and when?

When did you first receive treatment for the condition caused by the exposure?

What was your diagnosis? What is your diagnosis/prognosis today?

What type of treatment do you currently receive?

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