NOLOTIL, METAMIZOLE Victim Registration Form

De Micco & Friends represents victims of NOLOTOIL in Spain and worldwide.

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 the further procedures.

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

NOLOTIL VICTIM REGISTRAION FORM

    Name:
    Last name:
    Profession:
*  Nationality:
    Birth Date:
    Street 1:
    Street 2:
    City:
    ZIP:
    Country:
*  Your Email Address:
    Prefered Language:


*  Victim type:


*  I am intersted in:


*  Short Descriptiion of case:
    Damage date:
    Damage evidences:


    Damage location:
    Damage status:


    Damage amount:
*  Accept privacy policy:
*  Enter the security code shown:

 

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.


Phone: +34 871 955 077 | eMail: palma@demicco.es