First Name*:

Last Name*:

Your Email*:

Phone Number*:

Street Address*:

City*:

State*:

Zip Code*:

Best time to reach you?
 AM PM

Did you or loved one have hip replacement surgery?*:
 Yes No

Was Depuy hip relacement used?*:
 Yes No

If no, what was the Name and Model of hip replacement?*:

Year of hip replacement surgery*:

Have you experienced any of the following symptoms after your surgery*:
 Pain Swelling Fractured Hip Bone Loosening of Implant Implant Dislocation Other

Has your recalled/defective hip been replaced or been scheduled for replacement?*:
 Yes No

Other Comments*:

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You understand and agree to the following: your case may be evaluated by an attorney. You may be contacted by a represenative of a firm about this matter and the submission of your information in no way constitutes an attorney-client relationship.

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