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Guidant Defibrillator (defective defibrillator)

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Defendant:

Guidant (Defective Defibrillator)

*Describe Damages you Suffered:

Name of Implantee (if different):

Date of Birth:

Date of Death (if applicable):

Serial Number of unit (see ID Card):

Date of Implant:

Surgeon's Name:

Surgeon's Phone Number:

Was the device removed?

Yes No

If yes, when?

If yes, where?

Where is the device now?

Which Guidant Cardiac Debfibrillator was Implanted?

Ventak Prizm AVT:

Yes No

Prizm 2 DR:

Yes No

Contak Renewal:

Yes No

Contak Renewal 2:

Yes No

Vitality AVT:

Yes No

Renewal 3 AVT:

Yes No

Renewal 4 AVT ICD:

Yes No

Don't Know:

Yes No

Other Debfibrillator:

Yes No

If other, what is the name of defibrillator that was used?

What medical condition caused prompted the use of a defibrillator?

Additional comments:

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

I would like to be interviewed by a journalist.

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