Roundup Qualification

1

Have you lived, worked, or spent time near a military base, industrial site, or airport with known water contamination?* This field is required.

YESNO

2

Were you ever told your local water supply may have been contaminated with PFAS or “forever chemicals”?* This field is required.

YESNO

3

Did you regularly drink or cook with tap water from a potentially contaminated source?* This field is required.

YESNO

4

Was your diagnosis confirmed by a licensed medical provider?* This field is required.

YESNO

5

Did your diagnosis occur after at least six months of suspected PFAS exposure?* This field is required.

YESNO

6

Were you under the age of 75 at the time of your diagnosis?* This field is required.

YESNO

7

Has it been less than 10 years since your diagnosis?* This field is required.

YESNO

8

Has it been less than 10 years since your cancer diagnosis?* This field is required.

YESNO

9

Have you already filed a PFAS-related claim or hired a lawyer about this issue?* This field is required.

YESNO

10

Please Share Your First & Last NameThis helps our team find your records should you qualify.

First Name

Last Name

11

Type a question