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First Name
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Last Name
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Phone
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Email
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Did you or a loved one take Zantac for one year or more?
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Yes
No
Were you or a loved one diagnosed with any of the following?
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Liver Cancer
Bladder Cancer
Stomach cancer
Intestinal Cancer
Colorectal Cancer
Pancreatic Cancer
Esophageal/Nasal/Throat Cancer
Lung Cancer
Prostate Cancer (under 65 yrs old)
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