Manufacturers Des Lawsuit Claim Form

Learn if You Have a Claim Against Manufacturers of DES

DES Daughters v. Manufacturers of DES

DES Daughters are defined as women born between 1938 and 1971 who were exposed to DES before birth (in the womb). Litigation has been ongoing for years on behalf of DES victims.

Claimant Information

Are you submitting this information on behalf of yourself?

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Are you submitting this information on behalf of a family member?

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If yes, please provide: Name

Age

Relationship

Do you believe there exists documentary evidence that your mother used DES?

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Have you been diagnosed with any of the following conditions?

Clear cell adenocarcinoma of the vagina or cervix requiring hysterectomy or radiation.

Yes No

Uterine, cervical or tubal anomalies which cause: Primary infertility (never becoming pregnant), Secondary infertility (pregnant but can't carry to term), Miscarriage, Premature delivery preterm labor, Ectopic pregnancy, Hysterectomy, or Stillbirth.

Yes No

Vaginal anomalies, which cause Constrictions or bands making intercourse difficult or Adenosis (glandular growths) requiring; i. Multiple physician examinations and tests or ii. Multiple cryosurgeries, biopsies and surgery.

Yes No

Third-generation injuries associated with preterm labor or delivery resulting in premature birth and cerebral palsy, blindness or other neurological deficits or death of child.

Yes No

Infertility treatment due to infertility: In vitro fertilization , Gift, IUI, Surrogacy, Adoption.

Yes No

Additional Information

Please provide any other information you think may be valuable in your case:

Have you previously retained an attorney to represent you in this matter?

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Personal Information

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	Last Name
	Street / Apt	/
	City, State Zip

	Home Phone & Evening Phone (Same)	. . & . .
	E-Mail Address
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	Date Issue/Problem

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Learn if You Have a Claim Against Manufacturers of DES

DES Daughters v. Manufacturers of DES

Claimant Information

Have you been diagnosed with any of the following conditions?

Additional Information

Personal Information

Other Drugs / Medical Cases of Interest

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