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- Sheryl E. Berkowitz, Esq.
- Stephanie Fenstersheib, Esq.
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Request Form

Name*

Email*

Address*

Phone Number*

Best Time to Call*

Approximate date of initial implantation and at what facility?

Who was the doctor that performed the procedure?

Only Accepting Dow Corning Cases

Do you have a copy of your medical records from your breast implant surgery? Yes No

Have you had your implants removed? Yes No

Are / were your implants ruptured? Yes No

Have you registered with either of the Claims Office? Yes No

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

Are you currently being treated by a doctor or a specialist? Yes No

Have you received money from either Breast Implant Litigation Settlement Fund? Yes No

How Much?

Is an attorney currently representing you for your potential Breast Implant Litigation claim? Yes No

Other Comments

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Law Oﬃces of Fenstersheib & Berkowitz, P.A.

520 West Hallandale Beach Boulevard,
Hallandale Beach, FL 33009

(800) 529-6268

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