Veterans with Prostate Cancer Case Inquiry Form

* denotes required fields
Personal Information
* Name
* Address
City
State
Zip Code
Daytime Phone Number
Evening Phone
Mobile Phone
* E-mail Address
Branch of Service
Year of Discharge
   
Case Information
When did you receive radiation treatment at the Philadelphia VA Hospital?
 
Have you been informed that your treatment was with "seeds" which were improperly implanted?
 
Yes
No
If "yes", when were you so informed?
 
What is your most recent "PSA" result?
 
When was it taken?
 
Describe any harm you believe you may have suffered as a result of your radiation treatment at the VA Hospital.
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.