NOLOTIL - Victim Registration Form

De Micco & Friends represents victims of NOLOTIL in Spain.

If you (or a family member) are a victim of NOLOTIL consuming, you can register here free of charge and any obligations. We will inform you soon about further procedures.

Please use the following form, to tell us your case. We will contact you as soon as possible with further information.

NOLOTIL/METAMIZOL VICTIM REGISTRATION FORM

*  Salutation:
*  First Name:
*  Last name:
Profession:
*  Nationality:
 Birth Date:
*  Street 1:
 Street 2:
*  City:
*  ZIP:
*  Country:
*  Mobile phone:
*  Landline Phone:
*  Your Email Address:
*  Prefered Language:

*  Victim type:


*  I am interested in:


*  Short descriptiion of your case:
Damage date:
Damage evidence:


*  Damage location:
 Damage status:


Damage amount in Euro:
*  Privacy policy:

We will keep your data highly confidential! After sending your data, our team will contact you.

Your data protection is important for us! You can find the privacy policy here, which you accept with sending this form.