Dacthal Intake Form

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Are you bringing this claim for yourself, or on behalf of a family member?

If you are bringing this claim on behalf of a family member, please state their name, and their relationship to you.

Dacthal

Age of child

Child's diagnosis

When did the mother use Dacthal or was exposed to Dacthal?

Describe how the mother used Dacthal or was expsosed to Dacthal.

What evidence does the mother have to evidence the use or exposure to Dacthal?

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