Hip Replacement Claim
Name:
*
Address:
Phone:
*
Email:
*
Date of hip replacement:
Did you receive a recall letter from either your doctor, hospital or the manufacturer of the hip implant?
Yes
No
If so, when did you receive the letter?
Where did you have your hip implant procedure performed?
What is the name the doctor who performed your hip implant surgery?
Please tell us briefly about any related symptoms you have experienced since your hip replacement surgery:
Would you like a Lambert & Nelson, PLC representative to contact you regarding legal representation?
*
Yes
No
If so, what is your preferred contact method?
Email
Phone
Appointment
If Email: Would you also like for us to call you or set up an appointment?
Yes
No
If Phone: When is a good time to call you?
If Appointment: When is a convenient time for you to have a meeting at our offices?
Type the following:
For security purposes, please type the letters in the image.