Philips CPAP Pre-Qualification Form

Please answer the following questions to see if you qualify.

Start by answering the first question below. If you qualify based on the answer to that question, the next question will appear.

There are 5 total questions.

Fill out your name, email, and phone number to submit your information to VanDerGinst Law and we will reach out.

What is the brand name of the machine?*
What is the model number?*
What is your adverse event medical diagnosis?*
(lung cancer, respiratory issues, etc.)
When were you diagnosed? Be as specific as possible.*
When did you start using the machine?*
Name*
First Last
Email*
Phone*
By submitting this form you are agreeing to be contacted by an attorney or other law firm staff.

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