DePuy Class Action Intake Form

1869 Upper Water Street
Suite PH 301, Pontac House
HALIFAX, NS B3J 1S9
www.wagners.co
Email: [email protected]

DePuy Class Action Intake Form

Date:*
MM slash DD slash YYYY
Claimant’s Name (Individual who was issued a DePuy Hip Implant):
Name
First Middle Last
If Claimant is deceased, please check:
- Claimant is Deceased
Date of death:
MM slash DD slash YYYY
Claimant Address:
Address:
Home Phone
Facsimile:
Contact Address (If Claimant deceased):
Address:
Cell Phone*
Email*
Remainder of this form pertains to information about the Claimant
Date of Birth:
MM slash DD slash YYYY
Place of Birth:
Social Ins. #:
Health Card #:
Occupation:
Employer:
Retired
- Yes
- No
Marital Status:
Status
Single: Married: Common Law:
Status
Divorced: Widowed: Separated:
Date
Divorce Date: Widowed Date: Separated Date:
Spouse:
Name
First Middle Last
Date of Birth:
Month
Day
Year
S.I.N. No.:
H.C. No.
Children
(Only to be completed if Claimant is Deceased):
1. Name
First Middle Last
Date of Birth:
Month
Day
Year
S.I.N. No.:
H.C. No.
2. Name
First Middle Last
Date of Birth:
Month
Day
Year
S.I.N. No.:
H.C. No.
3. Name
First Middle Last
Date of Birth:
Month
Day
Year
S.I.N. No.:
H.C. No.
4. Name
First Middle Last
Date of Birth:
Month
Day
Year
S.I.N. No.:
H.C. No.
Hip Implant Information
Type of Implant:
DePuy ASR XL Acetabular System

Date of Surgery:
DePuy ASR Hip Resurfacing System

Date of Surgery:
Name of Surgeon:
Hospital where Hip Surgery was performed:
Do you have a copy of your medical records?
- Yes
- No
Do you currently still have the DePuy Implant
- Yes
- No
If the implant has been removed, please list the date of the surgery, the name of the surgeon who removed the implant, the name of the hospital at which the surgery to remove the implant was done, and a description as to why the implant was removed:
Medical information:
Have you experienced any of the following because of your hip implant? Please check any that apply.
- Pain
- Swelling
- Problems Walking
- Implant Loosening
- Fracture
- Dislocation
- Metal Debris
Please provide details:
Please indicate if and how your Depuy Hip Implant has affected your lifestyle, relationships, financial out-of-pocket expenses (medication, trips to the doctors, home care etc.), and lost earning capabilities:
Please note that we will never contact any persons listed below without your express consent. Family Doctor(s):
Provide details of doctors who would possess medical records related to medical conditions and/or treatment received arising from the use of your DePuy hip implant:
Detail Of Doctors
Name Phone # Address
Detail Of Doctors
Name Phone # Address
Detail Of Doctors
Name Phone # Address
Detail Of Doctors
Name Phone # Address
Specialist(s):
Provide details of any Medical Specialists you have seen regarding your DePuy Hip Implant or for any complications arising out of the use of your DePuy Hip implant:
Detail of Specialists
Name Phone # Address
Detail of Specialists
Name Phone # Address
Detail of Specialists
Name Phone # Address
Detail of Specialists
Name Phone # Address
Other Physician(s)/Hospital(s):
Provide details of any other medical practitioner or facility who would possess medical records related to medical conditions and/or treatment received arising out of the use of your DePuy Hip Implant:
Detail of Physicians
Name Phone # Address
Detail of Physicians
Name Phone # Address
Detail of Physicians
Name Phone # Address
Detail of Physicians
Name Phone # Address
Pharmacies:
Provide details of pharmacies that would possess prescription records verifying that you were prescribed any medications related to the treatment of your DePuy Hip implant:
Detail of Pharmacies
Name Phone # Address
Detail of Pharmacies
Name Phone # Address
Detail of Pharmacies
Name Phone # Address
Detail of Pharmacies
Name Phone # Address
Please briefly describe any medical problems you had before being issued your DePuy Hip Implant:

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Single:	Married:	Common Law:

Divorced:	Widowed:	Separated:

Divorce Date:	Widowed Date:	Separated Date:

Name	Phone #	Address

DePuy Class Action Intake Form

DePuy Class Action Intake Form

Claimant’s Name (Individual who was issued a DePuy Hip Implant):

Claimant Address:

Contact Address (If Claimant deceased):

Remainder of this form pertains to information about the Claimant

Marital Status:

Spouse:

Children

Hip Implant Information

Type of Implant:

Medical information:

Please note that we will never contact any persons listed below without your express consent. Family Doctor(s):

Provide details of doctors who would possess medical records related to medical conditions and/or treatment received arising from the use of your DePuy hip implant:

Specialist(s):

Provide details of any Medical Specialists you have seen regarding your DePuy Hip Implant or for any complications arising out of the use of your DePuy Hip implant:

Other Physician(s)/Hospital(s):

Provide details of any other medical practitioner or facility who would possess medical records related to medical conditions and/or treatment received arising out of the use of your DePuy Hip Implant:

Pharmacies:

Provide details of pharmacies that would possess prescription records verifying that you were prescribed any medications related to the treatment of your DePuy Hip implant: