| Please fill in all fields marked with a * |
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| Name | * |
| Address | |
| State | |
| Phone | * |
| Best Time To Call | * |
| Email Address | * |
| Approximate date of initial implantation and at what facility? * |
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| Who was the doctor that performed the procedure? |
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| Brand of Implant(s)? * |
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| Do you have a copy of your medical records from your breast implant surgery? YES NO |
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| Have you had your implants removed? YES NO |
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| Are/were your implants ruptured? YES NO |
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| Have you registered with either of the Claims Office? YES NO |
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| Which one(s)? | |
| Please list any health problems you currently have, such as SLE, dry eyes, joint pain and swelling, body and face rashes, myalgias, chronic fatigue, numbness and tingling in extremities, photosensitivity, etc |
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| Are you currently being treated by a doctor or a specialist? YES NO |
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| Have you received money from either Breast Implant Litigation Settlement Fund? YES NO |
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| How much? | |
| Is an attorney currently representing you for your potential Breast Implant Litigation claim? YES NO |
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| Additional Comments |
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Breast Implant Litigation cases / claims are being handled by the Law Offices of Fenstersheib and Berkowitz, located at the Law Offices of Robert J. Fenstersheib and Associates, P.A., 520 W. Hallandale Beach Blvd., Hallandale Beach, FL 33009
Copyright © 2009 Florida Personal Injury Attorney Robert J Fenstersheib & Associates All rights reserved.
Fenstersheib Law Offices - 520 W. Hallandale Bch Blvd, Hallandale, Florida 33009 (800) LAW-MAN8