PFAS Client Verification Form – Lusko Law

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Home > PFAS Client Verification Form

PFAS

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PFAS Client Verification Form

The information provided below is privileged attorney-client information. Please complete the form below and if you have any questions, contact us by calling (850) 308-4011 or email us.

First Name

Last Name

Date of Birth

Gender

Are you currently married?

Date of Marriage

Spouse's First Name

Spouse's Last Name

Spouse's Occupation

Are you making a claim for loss of consortium?

Contact Information

Preferred Phone Number

Email

Communication Preference:

Email

Phone Call

Text Message

Current Primary Residence

Please list your current primary address.

Current Address

Street Address

City

State

Zip Code

How long have you lived at your current address?

Who is your water provider at your current address?

Radio Field

Own

Rent/Lease

Former Addresses

Please list all former addresses since 1970.

Do you have another address to list?

Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Second Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Third Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Fourth Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Fifth Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Sixth Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Seventh Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Eighth Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Ninth Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

Do you have another address to list?

Tenth Former Address

Street Address

City

State

Zip Code

Who was the water provider at this address?

When did you live at this address?

Radio Field

Own

Rent/Lease

If you drank water from a private well listed at any of the above addresses, has the well water ever been tested for the presence of PFAS? If so, please upload a copy of the test results in the upload section below.

Medical History

Diagnosis (Primary)

Date of Diagnosis (Primary)

Other Related Diagnosis?

Related Diagnosis

Date of Related Diagnosis

Approximately when did you learn of your injury could be related to consuming contaminated water?

Medical Provider for Diagnosis

Medical Provider Address

Street Address

Street Address

State

Zip Code

Approximate Dates of Treatment

Are you still being treated by this provider?

Please describe the treatment(s) you have received (e.g. surgery, chemotherapy, medication, etc.)

Do you have medical records of your diagnosis?

Do you have an online portal to access records of your diagnosis?

Do you have another medical provider that you would like listed?

Medical Provider for Diagnosis

Medical Provider Address

Street Address

Street Address

State

Zip Code

Approximate Dates of Treatment

Are you still being treated by this provider?

Please describe the treatment(s) you have received (e.g. surgery, chemotherapy, medication, etc.)

Employment & Lost Wages

Are you currently employed?

Most Recent Employer

Occupation

Length of Employment

As a result of your diagnosis/injury, have you lost any wages or earnings?

Please provide a brief description of your losses:

Out of Pocket Expenses

Have you incurred any out of pocket expenses (medication costs, deductibles, etc.)?

Please provide a brief description of your out of pocket expenses:

Upload Files

Please upload any medical records, evidence of diagnosis, and test results by clicking on the button below. (Limit: 10 files)

Choose File

Verification

I declare that I have carefully reviewed the above information and verify that all of the information provided is true and correct to the best of my knowledge, information and belief.

Signature

Date

Textarea

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Tel: 850-308-4011
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