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Tainted Tissue Questionnaire
Did you or loved one receive a notice indicating you may have received infected or tainted tissue from a surgery?
Yes
No
If yes, whom did you receive this notice from?
What type of notice was received?
Date this notice was received:
Did the notice ask you to be tested for any diseases?
Yes
No
Were you tested?
Yes
No
If yes, please list results of tests:
Do you still have a copy of notice you received?
Yes
No
Did you receive an operation or surgery involving implantation of human bone or tissue?
Yes
No
If yes, type of bone or tissue:
What type of surgery was performed?
What state was your surgery performed in?
Name of Hospital, Surgeon, or Surgical Center:
Date surgery was performed:
Were there any complications or illnesses after surgery?
Yes
No
If yes, please describe:
Additional comments or information:
a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.