AGENT ORANGE QUESTIONNAIRE FOR LIVING VETERAN

Thank you for your inquiry. Please complete the questionnaire that follows the text of this message regarding your possible participation in an "Agent Orange" lawsuit. If you return the questionnaire to us electronically, we will review your information and update you as soon as possible as to the litigation. If you can’t submit it by email, you may also print the form out and submit it by mail – however it may take longer to respond to you. Thank you again very much for your time and interest.

Sincerely,

Gerson H. Smoger

3175 Monterey Blvd., Ste. 300

Oakland, CA 94602

Please fill in your e-mail address.

AGENT ORANGE QUESTIONNAIRE (please just submit the answers)

Name

Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Home Phone

Work Phone

Cell Phone

Email

Fax

Claimant's Date of Birth

Place of Birth

Social Security #

Dates of Viet Nam Service

Branch of Service and Rank

Briefly describe where you served, your duties, and where you believe you might have been exposed to herbicides, including Agent Orange:

What Agent Orange related conditions are you suffering from (If you have cancer please describe the cell type and location):

When were you diagnosed with each?

Please list any family members related by blood who have suffered or are suffering from the medical conditions you describe above?

Have you smoked? How many packs per day and for what period of time?

Are you currently receiving or seeking VA or SS disability? When did you first apply?

Have you made a claim for Veteran’s benefits related to your Agent Orange exposure? Has the claim been approved or rejected? When was it approved or rejected?

Were you aware of or did you participate in the original Agent Orange lawsuit or settlement? Please describe?

Are you or have you been 100% disabled? If so, when were you first 100% disabled and for what periods of time?

If so, when were you first 100% disabled and for what periods of time?

Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you.

AGENT ORANGE QUESTIONNAIRE (if you need to send it in by mail)

Please return forms to:

Smoger & Associates, PC

3175 Monterey Blvd., Suite #3 to submit or request a copy of

Oakland, CA 94602 this form.

Fax: (510) 531-4377

You may email: christexasinjurylaw@gmail.com

Click here to download the form.

AGENT ORANGE QUESTIONNAIRE

Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

Claimant's Date of Birth:

Place of Birth:

Social Security #:

Please identify two individuals (relatives or friends) who will always know where to contact you

and do NOT reside with you:

Name: Address: Phone #: Email:

Dates of Viet Nam Service:

Branch of Service and rank:

Briefly describe where you served, your duties, and where you believe you might have been

exposed to herbicides, including Agent Orange:

What Agent Orange related conditions are you suffering from (If you have cancer please describe

the cell type and location):

When were you diagnosed with each?

Please list any family members related by blood who have suffered or are suffering from the

medical conditions you describe above?

Have you ever taken any medications known as Zyprexa or Bextra?

Have you smoked? How many packs per day and for what period of time?

Are you currently receiving or seeking VA or SS disability? When did you first apply?

Have you made a claim for Veteran’s benefits related to your Agent Orange exposure? Has the

claim been approved or rejected? When was it approved or rejected?

Were you aware of or did you participate in the original Agent Orange lawsuit or settlement?

Please describe?

Are you or have you been 100% disabled?

If so, when were you first 100% disabled and for what periods of time?

Please feel free to add any additional comments you would like to make, or ask any questions

you might have and we will get back to you.

NOTICE: This message may contain legally privileged and confidential information intended

solely for the use of the addressee. If the reader of this message is not the intended

recipient, you are hereby notified that any reading, dissemination, distribution, copying, or other

use of this message or its attachments is strictly prohibited. If you have received this message in

error, please notify the sender immediately, and destroy this message and all copies and backups

thereof. Thank you

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Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
Work Phone
Cell Phone
Email
Fax
Claimant's Date of Birth
Place of Birth
Social Security #
Dates of Viet Nam Service
Branch of Service and Rank
Briefly describe where you served, your duties, and where you believe you might have been exposed to herbicides, including Agent Orange:
What Agent Orange related conditions are you suffering from (If you have cancer please describe the cell type and location):
When were you diagnosed with each?
Please list any family members related by blood who have suffered or are suffering from the medical conditions you describe above?
Have you smoked? How many packs per day and for what period of time?
Are you currently receiving or seeking VA or SS disability? When did you first apply?
Have you made a claim for Veteran’s benefits related to your Agent Orange exposure? Has the claim been approved or rejected? When was it approved or rejected?
Were you aware of or did you participate in the original Agent Orange lawsuit or settlement? Please describe?
Are you or have you been 100% disabled? If so, when were you first 100% disabled and for what periods of time?