Implanted Heart Devices Evaluation Form

If you would like us to review your case, please take a moment to tell us what happened. We will contact you within 48 hours to let you know if we can help.

Implanted Heart Devices Evaluation
* All indicated fields must be completed.

First Name:

Last Name:

Address:

City, State, Zip Code:

Phone Number:

*E-mail Address:

How did you learn about our firm?

If other, please specify

How did you find our website?

Device Type?

Medtronic    Guidant

Device Model Number?

Device Serial Number?

Original implantation date?

Name of Doctor who implanted original device?

Name of Hospital where original device was implanted?

Date of Replacement Surgery?

Name of Doctor who implanted replacement device?

Name of Hospital where replacement device was implanted?

Replacement Device Model Number?

Replacement Device Serial Number?

Brief description as to why a pacemaker or defibrillator was required?
   

IMPORTANT: An attorney client relationship is not established by sending us this e-mail. Such a relationship is established only after we have had the opportunity to review the facts surrounding your case and have spoken to you personally about the matter.