1. Is this information for

Self Someone Else

If self, complete no 2.

If someone else, complete name, address, phone, and email parts of no.1 and complete no. 3

2. Name Date of Birth

Address:

SSN: Phone: Cell:

Email:

Married Single Divorced

Spouse's Name:

3. The person's name:

Date of Birth Your Relationship to the Person

SSAN Living? Yes No

If no, date and cause of death and state where death occurred.

Date: State:

Cause of Death:

4. What surgery or procedure was done?

Date:

5. Where?

6. Surgeon's Name:

7. Have you (or the person) received a recall letter, or something else in writing, or telephone call, or other information indicating the tissue used in the surgery might be contaminated?

Yes No

If no, goto 7, skip number 8 and answer number 9. If Yes to 7, answer number 8 and skip number 9.

8. Date: Type of Correspondence

Sender's name and address:

Addressed to (name and address):

If written, do you have it? Yes No

If not, what happened to it?

Does the letter or other correspondence indicate that you should undergo blood or other tests to find out if you might have contracted a disease from contaminated body tissue?

Yes No

Have you had any blood or other tests since receiving it? Yes No

If yes, what, where, when and what results?

9. Why do you think you might have received contaminated tissue?

10. Have you (or the person) had blood or other tests at any time since surgery?

Yes No

Where?

a. For those who have a letter or what sounds like a reasonably reliable indication of receiving potentially contaminated tissue, we will send you a package containing:
• Attorney representation agreement
• Authorizations to release medical information
•A contaminated tissue litigation information sheet
•Information about our law firm
•A letter asking you to send us the your recall letter (if applicable) and any related medical records you have
• A return envelope

b. For those who don’t have a reasonably reliable indication of receiving potentially contaminated tissue:

There is no practical means for us to try to determine if a person received contaminated tissue, until and unless a doctor, hospital, other medical care provider, or medical supplier notifies a person of this. This information does not appear in a person’s surgical records. The person is free and encouraged to ask his or her doctor about this, and we will be happy to talk again with anyone who gets confirming information but doesn’t have it now. But we are only going to pursue cases where the person can supply us with confirming information.

DISCLAIMER:
Your email is initiated at the www.hpcbd.com website, and is directed to one or more attorneys or staff persons at Hill, Peterson, Carper, Bee & Deitzler, PLLC. The content of any submitted email is provided by and is the responsibility of the person posting the email communication, meaning the person who is filling out this form and submitting it to the law firm. In making your inquiry in this manner, you understand that your email will not create an attorney-client relationship and will not necessarily be treated as privileged or confidential. You acknowledge that any reliance on material in or through such email communications is at your own risk.