Oplaw

1
Did you live or work for at least 30 days at Camp Lejeune between 1953 and 1987 OR were you exposed prior to birth?
Yes - Lived
Yes - Employed
Yes - Prior To Birth
No
2
Please select the reason the injured individual was at Camp Lejeune
Military
Military Dependent
Civilian Employee
Other
3
If you were in Camp Lejeune between 1953-1987, what was the last date when you lived/worked there within that time frame?Click onto month and year to adjust the date
4
Were you born before 1988?
YESNO
5
Have you suffered illness or injury that might be related to exposure from Camp Lejeune?
YESNO
6
Were you diagnosed with cancer or any other illness/injury?
Leukemia
Aplastic Anemia and More Myelodyplastic Syndromes
Birth Defects
Bladder Cancer
Esophageal Cancer
Female Infertility
Kidney Cancer
Liver Cancer
Lung Cancer
Multiple Myeloma
Non-Hodgkin's Lymphoma
Parkinson's Disease
Renal Failure
Death
Scleroderma
Appendix Cancer
Brain Cancer
Bile Duct Cancer
Colorectal Cancer
Gallbladder Cancer
Intestinal Cancer
Pancreatic Cancer
Prostate Cancer
Sinus Cancer
Soft Tissue Sarcoma
Spinal Cancer
Thyroid Cancer
Breast Cancer
Hepatic Steatosis (Fatty Liver Disease)
Miscarriage
Neurobehavioral Effects
None
Other
7
What was the date of diagnosis?Click onto month and year to adjust the date
8
Did you file a Veterans Affairs claim in relation to this?
YESNO
9
Was the claim accepted or denied?
Yes
No
In Process
10
Are you represented by an attorney for the VA claim?
YESNO
11
What is your date of birth? Click onto month and year to adjust the date
12
What is your full name?* This field is required.
First Name
Last Name
13
What is your email address? * This field is required.
Please note, I will be reaching out by email to confirm your appointment
14
Phone Number* This field is required.
Please note, I will respond by text to confirm your appointment
15
What is your mailing address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
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Angola
Anguilla
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Aruba
Australia
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The Bahamas
Bahrain
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Belize
Benin
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
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Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Denmark
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
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Hungary
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Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Sierra Leone
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South Ossetia
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eSwatini
Sweden
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Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
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Other
Country
16
How did you hear about us?* This field is required.
Please Select
Please Select
Referral
Instagram
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Other (Please specify...)
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