Vaginal Mesh Injury Intake

Full Name (required)

Address (required)

Phone (required)

Email (required)

INFORMATION REGARDING MESH IMPLANT:

What was the status of your health prior to the insertion of the Mesh?

What was the condition for which you had surgery in which the Mesh was used?

Date of surgery:

What type of procedure was performed?

Name and address for the doctor who performed your surgery:

Name and address of the hospital or surgery center where your surgery was performed:

What company manufactured your Mesh?

INJURY INFORMATION

Date that you first realize that you had a problem with the mesh?

Have you experienced any of the following symptoms?(Check all that apply)
PainInfectionVaginal erosionBladder perforationsUrinary problemsIncontinenceVaginal scarringMesh erosionPain during sexual intercourse
Other Symptons:

For any of the above conditions checked please state the date each problem began:

Has a doctor told you that your symptoms were caused by the Mesh?

Has your Mesh been removed?

If YES, the date it was removed

If YES, was all of it removed, or only part?

If YES, has it been replaced?

If YES, with what?

Name and address of the surgeon who removed the implant:

Name and address of hospital where Mesh was removed:

Do you know the manufacturer, product or lot number of the mesh used?

MEDICAL PROVIDER INFORMATION:

1) Name of Doctor/Hospital

Address

Reason

Date of visit(s)

2) Name of Doctor/Hospital

Address

Reason

Date of visit(s)

3) Name of Doctor/Hospital

Address

Reason

Date of visit(s)

4) Name of Doctor/Hospital

Address

Reason

Date of visit(s)

Have other lawyers been contacted about this case:

If so, by who:

Do you have health insurance:.
(Blue Cross, Aetna, Medicare, Medicaid, etc.)

If yes, what is the name, address and telephone of the company (usually located on the back of the insurance card):

Have you received other medical treatment? If so, please name each hospital, doctor, physical therapist, etc., where you received treatment regarding this incident.
If needed, please use a blank sheet to complete this section.
Name of Provider

Address and Phone/Fax No.

Are you currently taking medication?

If yes, what is type:

Where do you have this medication filled (Name of Pharmacy and Address):

Do you know the total of your current medical bills?

If yes, how much are they?

Please provide copies to our office

AMOUNT OF BILL

ER Hospital Bill:

Ambulance Bill:

ER Doctor’s Bill:

General Doctor’s Bill:

Co-Pays:

Mileage Costs:

Time Spent in the Emergency Room:

Time Spent at the Doctor’s Office:

Pharmacy Bills:

Other Bills Incurred Because of the Accident:

If yes, what were they for and when: Provide name & address of doctors & hospitals.

What other, if any, medical problems did you have before the mesh was implanted:

Did you miss any time from work because of the accident or injury:

If yes, how much time have you missed from work:

How much do you make per hour or per pay period:

Was your husband, a friend or a relative required to miss work to help you because of your accident or injury:

Are you on Social Security Disability or SSI?

If you are receiving SSI, do you understand a settlement may affect your benefits:

Have you talked to an Insurance Claims Adjustor or someone from the company:
If yes, what is their name and the name of their company:

Have you signed any paperwork from an insurance company or from the company since your mesh was implanted:

If you have signed paperwork do you still have a copy of what you signed:

Have you received any compensation for the accident?

If so, who paid you the compensation?

Have you ever filed a lawsuit before?

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