My Talc Story

Name(Required)

First Last

Injured Party Name (If Different)

First Last

Address(Required)

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

Your Email(Required)

Your Phone(Required)

Injured Party Date of Birth(Required)

Injured Party's Last Four Digits of SSN(Required)

1. Do you have out-of-pocket medical expenses in excess of $250,000?(Required)

Yes

Do you have copies of any medical bills?

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

You can either upload your document here or provide to The Smith Law Firm by emailing documents@smith-law.org.

2. Do you have lost earnings in excess of $250,000 caused by your diagnosis and treatment?(Required)

Yes

What documentation do you have for these lost earnings? (i.e. W-2, tax returns, pay stubs, etc.)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

You can either upload your document here or provide to The Smith Law Firm by emailing documents@smith-law.org.

3. Tell me about your background.(Required)

4. Tell me about your diagnosis and cancer treatment.(Required)

5. Tell me about the pain, suffering, and mental anguish you have experienced due to your cancer and cancer treatment.(Required)

6. Describe how your life changed due to your cancer diagnosis and treatment.(Required)