Is the Claimant currently on appeal or received an unfavorable VA decision within the last year?* —Please choose an option— Yes No Does Not Apply
How Did You Hear About Us?* —Please choose an option— Unknown Website/Internet Event Attorney/Professional Referral Client Referral Lawyers.com
Do you have a current or previous diagnosis of cancer?* —Please choose an option— Yes No
—Please choose an option— Bladder Bone Brain Cervical Colon Hodgins Lymphoma Kidney Leukemia Liver Multiple Myeloma Non-Hodgins Lymphoma Breast Other Lymphoma Ovarian Pancreatic Prostate Cancer Respiratory (larynx, Pharynx, Esophageal, Lung) Skin Cancer (Melanoma) Soft Tissue Sarcoma Small Intestine Cancer Stomach Cancer Testicular Cancer Thyroid Cancer Uterine Cancer
Are you Employed?* —Please choose an option— Yes No
Were you or a loved one seriously injured after 9/11/2001 in Iraq or Afghanistan by an IED, rocket, or similar incident causing serious bodily injury? —Please choose an option— Yes No