DePuy ASR XL Acetabular System Hip Implants and DePuy ASR Hip Resurfacing Implants Case Evaluation Form


We are now accepting cases in your area. If you think you have been affected by DePuy ASR XL Acetabular System Hip Implants and DePuy ASR Hip Resurfacing Implants. Print this form. Fill it out and Fax to 520-881-0740 or mail to the address listed below for a free legal evaluation.

Questions with an asterisk (*) are required.

Client Information


* Name: __________________________________

* Address: __________________________________

* Phone: __________________________________

* Email: __________________________________

* DOB: __________________________________

Married: Yes No Date of Marriage

Name of Spouse: __________________________________

Hip Implant Information


DePuy ASR: Yes No Not Sure

Date Of Implant Surgery: ___________________

Where was the surgery done: ___________________

Hospital: ___________________

County: ___________________

Letter from your surgeon or Johnson & Johnson about the DePut Hip?
Yes No Don't Know

Do you have an ID card with Model Number?
Yes No

Injury

Have there been any surgical revisions?
Yes No

If yes, how many revisions? ___________________

Dates: ___________________ ___________________ ___________________

What other problems have you had relating to your hip implant ___________________
________________________________________________________________________
________________________________________________________________________

Doctors/Hospitals/Facilities


Prescribing Dr.: ___________________ Hospital: ___________________

Treating Dr.: ___________________ Hospital: ___________________

Pharmacy: ___________________

Other


Have you contacted other firms? Yes No

If yes, who?: ___________________

Are you a smoker? Yes No

The use of this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be written on this form. By signing this form, you have read and agree to our disclaimer.

Name: ___________________

Signature: ___________________ Date: ___________________

MOELLER LAW OFFICE
3433 E FORT LOWELL RD STE 105 TUCSON, AZ 85716-1791
PHONE: 520-795-8852 - TOLL FREE: 877-369-8800
“ARIZONA LAYWERS PROTECTING ARIZONANS”