PAGCL- Caused by Pain Pump Implants
 

Register Your Complaint

Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email Address:
Date of Birth:
Marital Status: Single Married
On whose behalf are you inquiring? Self Other
Is the person you are inquiring on behalf of deceased? No Yes
If yes, Date of Death:
Date of Surgery:
Name & Address of Physician:
Manufacturer of Pain Pump:
Date pain pump was installed:
Date pain pump was removed:
Total time pain pump was used:
Are you experiencing shoulder problems? Yes No
Description of Shoulder Symptoms:
Are you still experiencing these symptoms? Yes No
Were you hospitalized or treated by a doctor for these symptoms: Yes No
If yes, name of hospital or doctor and length of stay:
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