Zantac/Ranitidine California Retailer Survey

California Zantac/Ranitidine Cancer and Purchase Location Survey

Chaffin Luhana is diligently working on your potential Zantac case and we urgently need your assistance.

Please complete the form below to the best of your ability.

It is important that you select any/all retailers/pharmacies that you may have purchased Zantac from. Your responses are critical to your claim.

Name(Required)

First Last

Email(Required)

If you were diagnosed with breast cancer, please select the type below(Required)

Ductal Carcinoma

Non-Ductal Carcinoma

Unknown

I Was Not Diagnosed With Breast Cancer

Zantac/Ranitidine Purchase Locations

Other Retailer / Location (not listed above)

Do you have a loyalty/rewards card for any of the retailers you selected?(Required)

Yes

Did you purchase Zantac/ranitidine by prescription, over-the-counter, or both?(Required)

Prescription Only

Over-The-Counter Only

Both