Mirena Class Action Intake Form

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

Mirena Class Action Intake Form

Date:*
MM slash DD slash YYYY
Claimant's Name (Individual who was prescribed Avandia):
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.
History of use:
Used Mirena From To
Medical information:
Have you experienced any of the following while using the Mirena device? Please check any that apply.
- Uterine Perforation
- Pelvic Inflammatory Disease
- Migration of the Mirena device
- Other
Please provide details:
If you have children, did you receive the Mirena device within six weeks of your pregnancy?
- Yes
- No
Please provide details:
Did you experience any pain, bleeding, or fainting during the insertion process?
- Yes
- No
Please provide details:
Was a string test performed within six weeks of having received the Mirena device?
- Yes
- No
Please provide details:
Have you had or do you have plans to have the Mirena device surgically removed?
- Yes
- No
Please provide details:
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 the Mirena device.
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 the Mirena device or for any complications arising out of the use of the Mirena device:
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 the Mirena device:
Detail of Physicians
Name Phone # Address
Detail of Physicians
Name Phone # Address
Detail of Physicians
Name Phone # Address
Detail of Physicians
Name Phone # Address
Please briefly describe any medical problems you had before using the Mirena device:
Have you been prescribed any other birth control medication in addition to Mirena?
- Yes
- No

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Single:	Married:	Common Law:

Divorced:	Widowed:	Separated:

Divorce Date:	Widowed Date:	Separated Date:

Used Mirena From	To

Mirena Class Action Intake Form

Mirena Class Action Intake Form

Claimant's Name (Individual who was prescribed Avandia):

Claimant Address

Contact Address (If Claimant deceased):

Remainder of this form pertains to information about the Claimant

Marital Status:

Spouse:

Children

History of use:

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 the Mirena device.

Specialist(s):

Provide details of any Medical Specialists you have seen regarding the Mirena device or for any complications arising out of the use of the Mirena device:

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 the Mirena device: