If you would like more information about a free Welding Rod Disease Evaluation, please fill out the form below and a caring professional will contact you as soon as possible. You may also call attorney Lane Clack toll free at 1 (800) 799-2234.

Your Contact Information
Full Name:
Address:
City:
State:
Zip:
Phone:
Email:
Relationship If you are requesting information on someone's behalf, please fill out this portion.
Injured Person's Name:
Your relationship:
Date of Birth:
Work History Please check the box next to the statements that apply to you.
Worked as a welder.
Worked around industrial welding.
Worked with or around fumes from welding rods.
If you said yes, for how long have you been exposed?	Years
What was the date of your last Exposure?
Medical Information Please select yes or no for the applicable questions.
Have you been diagnosed with Parkinson's Disease?	Yes: No:
If yes, then when?
Have you been diagnosed with Manganism	Yes: No:
If yes, then when?
If you have experienced any of the following symptoms, please check the corresponding box.
Tremors in hands, arms, legs or feet:
Infrequent blinking and lack of facial expression:
Difficulty in maintaining balance:
Slow or delayed movement:
Rigid or stiff limbs:
Slow response to questions (memory loss/mental slowing):
Comments and Suggestions: