Defendant:
(who caused the harm?)
GUIDANT DEFIBRILLATOR PACEMAKER
Title:
(describe the nature of your complaint in one short sentence)
What is the best way to contact
you? (time, phone number, etc)
Additional contact information:
Date of Birth: (mm dd yy)
Whom are you inquiring on behalf
of? (self, minor, other)
If you are NOT inquiring on your
own behalf, what is your relationship?
Is the person deceased?
Yes
No
If deceased, what is the cause of
death as stated on the death certificate?
Date of Death:
Was there an autopsy performed?
Yes
No
During what period of time was the
pacemaker implanted? Start date:
End date:
For what diagnoses or condition
was the defibrillator prescribed?
Which Guidant Debfibrillator was
Implanted?
Ventak Prizm AVT
Prizm 2 DR
Contak Renewal
Contak Renewal 2
Vitality AVT
Renewal 3 AVT
Renewal 4 AVT ICD
Other Debfibrillator
Don't Know
If other, what is the name of
defibrillator that was used?
Date pacemaker was implanted:
Is the defibrillator still
implanted?
Yes
No
What medical condition caused
prompted the use of a defibrillator?
Please describe any problems or
injuries caused by the defibrillator, e.g., electrical shock,
audible beeping, irregular heartbeat, but no device response.
YOUR INFORMATION
First Name:
Last Name:
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Address:
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