Complete this intake form and a team member will contact you and further investigate the mercury exposure you may have endured. Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Did you or a family member work at the chlorine plant in Deer Park, Texas? * Myself Family Member Were you or your family member a contractor or employee at the chlorine plant in Deer Park, Texas? * Contractor Employee Family Member was a Contractor Family Member was an Employee If you or a family member worked at the plant for a contracting company, what company was it? How long did you or your family member work on site at the chlorine plant in Deer Park, Texas? Please include any additional details or information you may think is important for us to know about your symptoms and exposure. Thank you for completing this initial form. A team member will be in contact with you to further investigate the mercury exposure you may have endured.
