202-780-5153 info@nidellaw.com

Fluoride Questionnaire

Nidel Law, P.L.L.C. is currently investigating potential injuries as a result of fluoridation of drinking water. If you or your child has what you believe to be dental fluorosis, feel free to answer the following questionnaire. PLEASE NOTE – ANSWERING THIS QUESTIONNAIRE DOES NOT INDICATE THAT THIS FIRM OR ANYONE WILL BE FILING A LEGAL CLAIM ON YOUR BEHALF. Depending on the results of this investigation, someone may follow-up with you and your injury.

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Fluoride Questionnaire

NameFull Name
Subject
AddressStreet Address
City
State
Zip Code
Phonebest contact phone
From birth until age 18 did you drink fluoridated city water for most of your water needs?
From birth until age 18 did you drink fluoridated city water for most of your water needs?
What is your age (or the age of the child for whom you are filling the form out?
Please indicate if the following responses are submitted on behalf of either yourself or your child under the age of 18.
Do you have written records (check stubs, utility bills, etc) documenting your being a customer of your water utility / utilities that provided fluoridated water during your years 0 – 10 years old?
Did you consume well water during the period from 0 – 10 years old for any period more than three months?
Did you consume bottled water for any more than 20% of your water needs during the time from 0 – 10 years old?
As a child were you given prescription fluoride supplements (pill, drops, etc)?
If supplements were prescribed and taken, do you have medical records or other proof documenting the name of the physician, dentist, or other health professional that provided the fluoride supplements, the brand name of the supplements provided, and the length of time the supplements were taken?
Did your physician, dentist, or other health provider ask you detailed questions about your other possible sources of fluoride prior to prescribing the fluoride supplements?
Did you use fluoridated toothpaste during the years 0 – 10?
Do you have close-up photos of your teeth?

If you have photos of your teeth, you may submit them to fluoride@nidellaw.com. Two photos, no more than four, may be submitted, to include an in-focus, close-up of the teeth with the lips pulled back, showing only the lips and teeth, and a full-face-shot photo with teeth exposed. Examples of photos can be found below.

Minority populations in many cases ingest more fluorides than Caucasians, but persons of all races and ethnic backgrounds ingest fluorides and may be affected. If you would like to share your racial or ethnic background (not required), please check appropriate box:
Please Describe your Case:
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PicturesYou can also email photos to info@nidellaw.com
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