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
Date of Surgery:
Name & Address of Physician:
Manufacturer of Pain Pump:
Date of Surgery When Pump Installed:  
State Where Surgery Performed:  
Total number of days the pain pump was used:
Are you experiencing shoulder problems? Yes No
Has your physician recommended / performed a shoulder replacement surgery?
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:
How did you hear about us?