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252-283-8522 (NC)

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Camp Lejeune Water Contamination Intake Form

Free Claim Evaluation!

First Name*

Last Name*

Email*

Phone Number*

Did you spend time at Camp Lejeune before 1988?

Yes

How long were you at Camp Lejeune?

Less than 30 days

More than 30 days

Did you suffer any of the following illnesses after your time at Camp Lejeune?

Adult leukemia

Aplastic anemia and other myelodysplastic syndromes

Bladder cancer

Kidney cancer

Liver cancer

Multiple myeloma

Non-Hodgkin’s lymphoma

Parkinson’s disease

Miscarriage

Esophageal cancer

Lung cancer

Leukemia

Other injury

Other cancer

Other illness

Are you currently represented by an attorney for this matter?

Yes

Disclaimer

Submission of this form does not create any type of attorney-client relationship.

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The Amos Law Firm, PLLC

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Camp Lejeune Water Contamination Intake Form

Free Claim Evaluation!

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