H Lee Moffitt Cancer Center & Research Institute

Centers for the Treatment of Mesothelioma Cancer

H. Lee Moffitt Cancer Center & Research Institute
University of South Florida
12902 Magnolia Drive
Tampa, Florida 33612
Patient Information: (888) MOFFITT or (888) 663-3488
www.moffitt.usf.edu

If you or a loved one have been diagnosed with mesothelioma, contact James F. Humphreys and Associates today to arrange a free consultation. Please fill out as many questions as possible.

Please select the Asbestos-related disease with which you or a loved one has been diagnosed:

If diagnosed, when did the diagnosis take place?

In what state did the Asbestos exposure occur?

Please select the manner in which the Asbestos-Exposure occurred:

If exposure to Asbestos occurred at work, what was the name of your employer?

What was the approximate date of exposure to Asbestos?

Additional relevant information:

* First Name:		* Last Name:
* Your Zipcode:		* E-Mail:
* Phone Number:
Okay to call you at this number?		Yes No
To Prevent Automated Submissions, Enter the 4 Digit Number Shown Below: 3440
NOTE: We will attempt to respond within 24-48 hours. Please check your email to confirm our receipt of your inquiry.

Charleston, West Virginia	Washington, D.C.
United Center, Suite 800 500 Virginia Street East Charleston, WV 25301 Toll Free:(800)442-1161	1200 New Hampshire Ave. Suite 510 Washington, D.C. 20036 Toll Free: (866) 392-5558