Asbestos Information Center

Asbestos and Mesothelioma Contact Form

Name

E-mail Address

Phone Number

When did you first have contact with asbestos?

Where were you when the contact occurred?

What were you doing when the contact occurred?

Who owns the property where the contact occurred?

How many times have you been exposed to asbestos?

Did you or your employer purchase the product that contained the asbestos?

Were you working at the time of the exposure? For whom?

If you encountered the asbestos at work, do you recall any training, warnings or provision of protective gear by your employer to protect you from or educate you about asbestos?

What disease or injury (mesothelioma, asbestosis, lung or other cancer) has occurred as result of the asbestos exposure?

Please list your treating physicians and other medical providers

Do you or have you smoked? How much and when?

When did you first receive treatment for the condition caused by the exposure?

What was your diagnosis? What is your diagnosis/prognosis today?

What type of treatment do you currently receive?

DISCLAIMER: This site and any information contained herein are intended for informational purposes only and should not be construed as legal advice. Seek competent legal counsel for advice on any legal matter.

- Mesothelioma Information Center
- Asbestos Information Center

If You or Someone You Know May Have Mesothelioma Call Us Today at the Number Below! 800.849.5291

The Law Offices of Wallace & Graham provides effective, compassionate representation in mesothelioma litigation and asbestos disease. Our attorneys serve clients statewide in North Carolina, including Charlotte, Raleigh, Asheville, Winston-Salem, Wilmington and Greensboro; and nationwide, including Florida (Miami, Fort Lauderdale, Jacksonville, Texas (Corpus Christi, Houston, Dallas, El Paso), California (San Francisco, Los Angeles), New York (New York City), Ohio (Cleveland), Illinois (Chicago), Connecticut (Hartford), Pennsylvania (Philadelphia, Pittsburgh), Massachusetts (Boston), Louisiana (New Orleans). In addition to clients throughout the United States, we represent people internationally, including the United Kingdom, Australia and the Philippines. When necessary, we will associate with local counsel to help clients with their claims.

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