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Patient Information

First Name *

Middle Name

Last Name *

Date of Birth *

Date of Death (if patient is deceased please complete)

Address *

City *

State *

Zipcode *

Phone *

Email *

Phone

Best time of Day

Any other communication preferences (such as day of the week)

The patient was a firefighter after 1960 for at least 4 years and was exposed to AFFF** (includes civilian firefighters)

The patient was in the military or at least 4 years and was exposed to AFFF** (Aqueous Film Forming Foam)

I would like to be contacted to see if I match geographic criteria (for patients who do not meet any of the first two options)

Facility Name *

Facility Address *

Full Physician Name *

Date of Diagnosis *

First Name

Middle Name

Last Name

Date of Birth

Relation to Patient

Address

City

State

Zipcode

Phone

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