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Was Your Cancer Caused by Roundup?
Case Evaluation
Step
1
of
5
20%
[1.] Diagnosis
Have you or a loved one been diagnosed with any of the following? Check all that apply.
Non-Hodgkin's Lymphoma
Lymphoma
Leukemia
Other Cancer or Diagnosis
No Diagnosis
Did a loved one die as a result of any diagnosis selected?
Yes
No
When was the diagnosis made?
*
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Month
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
How old were you when you were diagnosed?
Under 65
Between 66 and 80
Over 80
[2.] Exposure
When were you exposed to roundup?
After 1985
Before 1985
I was never exposed to roundup
How long were you exposed to Roundup?
- Select Duration -
Less Than 2 weeks for only one year
2 weeks/year for more than two years
More than 1 month of exposure
Please check where/how you were exposed to Roundup
Landscaping
Farming
Other Agriculture
Home Use
[3.] Prior Diagnosis
Please indicate if you had any of the following diagnoses or treatments:
HIV/AIDS
Organ Transplant
Prior Chemotherapy Treatment
None of the Above
[4.] Additional Information
Please list any additional details of you (or your loved ones) diagnosis, roundup exposure, add any additional information that will help us determine if you or your loved one qualifies for compensation.
[5.] View Report
See your instant case analysis report upon submission of this form.
First Name
*
Last Name
*
Email
*
Phone Number
*
Select Your State
*
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Armed Forces Americas
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*
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